SyMPLER Palliative Care: a qualitative study of patient experiences with a symptom monitoring program and self-referral to specialty palliative care

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Agne, Alice A Gaughan, Laura J Rush, Jennifer L Eramo, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7420494/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Symptom monitoring programs (SMP) and specialty palliative care (PC) improve health-related quality of life through timely symptom management for patients with lung cancer. The primary aim of this study was to assess patients’ perspectives about the feasibility and acceptability of a SMP with a prompted palliative care self-referral option. Methods This is a single-institution qualitative study of patients with lung cancer enrolled in a single-arm feasibility study of a mobile health application (app) that facilitates on-demand reporting of cancer-related symptoms and prompts patients to self-refer to PC for symptom management. Interview participants were purposefully sampled based on high (≥ 3 uses) vs low (0–2 uses) app engagement during the first three months of study enrollment. Questions focused on feasibility and acceptability of the SMP as well as the five main components of the intervention. Individual interviews were conducted from May 2024 – May 2025 by telephone, recorded, transcribed verbatim, and analyzed using thematic analysis. Results Thirty-one patients were interviewed; 21 with high and 10 with low app engagement. Participants were mostly white (93.5%), female (67.7%), and ≥ 60 years of age (61.3%). Most participants were willing and able to report symptoms through the study app and self-refer to PC if needed for symptom management. Participants described technology concerns and low understanding of PC as primary barriers to SMP engagement and PC self-referral, respectively. Conclusion Patients reported that an app-based SMP with integrated PC self-referral was both feasible and acceptable. Incorporation of participant feedback may improve engagement with future iterations of this intervention. Symptom monitoring program Digital behavioral change intervention Palliative care Cancer Figures Figure 1 Figure 2 Introduction Most patients report at least one uncontrolled symptom (e.g. pain, nausea, anxiety) after a cancer diagnosis [ 1 ]. Symptoms often fluctuate during an individual’s cancer trajectory [ 2 ], and this can impact patients’ health-related quality of life (HRQOL) and cancer-related survival [ 3 , 4 ]. For example, thoracic malignancies are highly symptomatic, with > 90% of patients reporting at least one bothersome symptom [ 5 ]. Among patients with metastatic non-small cell lung cancer (NSCLC), fatigue, insomnia, and dyspnea predominate during systemic cancer treatment while pain increases with disease progression and declining performance status [ 6 ]. Therefore, early symptom identification and treatment can be crucial to improve patient experiences and outcomes during cancer care. Two evidence-based approaches – symptom monitoring programs (SMPs) and specialty palliative care (PC) – have independently been shown to improve HRQOL, reduce healthcare utilization, and prolong survival through identification and treatment of cancer-related symptoms [ 7 – 11 ]. In SMPs, patients systematically report cancer symptoms via a digital interface (e.g., tablet, computer, smartphone device) to their oncology clinicians who can then address uncontrolled symptoms between clinic visits [ 12 – 14 ]. SMPs rely on clinician response to patient-reported symptoms as symptom reporting alone is non-superior to usual care [ 15 , 16 ]. In contrast to a digital reporting approach, PC uses an interdisciplinary team of specialty-trained physicians, advanced practice providers, and nurses to address cancer-related distress with a particular focus on symptom management [ 17 ]. As SMPs rely on the responsiveness and primary symptom management skills of oncology clinicians [ 9 , 18 , 19 ], prior SMPs have not impacted patient receipt of specialty PC, despite high patient-reported symptom burden [ 20 , 21 ]. Integration of PC into SMPs remains a unique opportunity to improve patients’ cancer-related symptoms. To advance the science of SMPs, we developed SyMPLER: Sy mptom M onitoring P rogram L inked to E lectronic R eferrals. To our knowledge, SyMPLER is the first digital behavioral change intervention (DBCI) that integrates PC into an SMP via a mobile health (mHealth) application (app). DCBIs deliver cues to encourage a particular behavior, accompanied by positive reinforcement to encourage the continuation of the behavior over time [ 22 ]. The SyMPLER DCBI delivers weekly cues via text reminders that encourage patients to self-report the severity of their cancer-related symptoms. It also allows patients to request and then receive help, a form of positive reinforcement, via two means: oncology clinician callback and/or PC self-referral. An option for oncology callback and palliative care self-referral within an SMP represents an important innovation: it has the potential to improve access to specialty PC in a highly patient-centered way through symptom self-assessment and allowing the patient to decide whether and when to seek PC. Using principles from behavioral economics [ 23 ], SyMPLER prompts patients to make active choices about seeking help while minimizing logistical barriers (e.g., “Do you want to see a palliative care specialist at your next oncology visit?”; “Do you want a member of the oncology team to contact you?” ). The primary aim of this qualitative study is to explore patients’ perspectives about the feasibility and acceptability of SyMPLER. Findings from this study can inform future efforts to test and if effective, implement SyMPLER in oncology settings. Methods This study was approved by the Institutional Review Board at The Ohio State University in Columbus, Ohio, USA, and was conducted in accordance with the Declaration of Helsinki. Sample selection and recruitment Participants were recruited from the SyMPLER parent study (NCT06396598), a prospective single-arm feasibility study of SyMPLER in patients with lung cancer. Lung cancer was chosen as the target of SyMPLER due to its high symptom burden across all cancer stages during the first 6 months after diagnosis [ 5 ]. The SyMPLER parent study included adults (≥ 18 years old) with any stage thoracic malignancy (non-small cell lung cancer, small cell lung cancer, mesothelioma, or thymic carcinoma) who were within 12 weeks of their first outpatient oncology appointment at this National Cancer Institute Comprehensive Cancer Center. Participants were required to have access to a smartphone device and speak and read English; individuals who had been referred to outpatient PC prior to study enrollment were excluded. Parent study participants were approached consecutively via email for qualitative interviews after meeting eligibility criteria, which were 3 instances of using the study app for symptom reporting or at 3 months after enrollment in the SyMPLER study, whichever occurred first. Three follow-up attempts could be made via telephone, and verbal consent was obtained at the beginning of each interview. Participants who consented for qualitative interviews were categorized based on their SyMPLER use: the “high engagement” cohort used SyMPLER ≥ 3 times whereas the “low engagement” cohort used SyMPLER < 3 times within 3 months after enrollment. Recruitment for interviews ended when thematic saturation was achieved [ 24 ]. Participants received a $ 25 gift card following the interview. SyMPLER symptom monitoring program The SyMPLER intervention included five main components (Fig. 1 ): (1) an introduction to PC via online and print educational materials curated by the Center for the Advancement of Palliative Care (CAPC) [ 17 ], (2) weekly secure messaging system (SMS) text reminders encouraging participants to report symptoms, (3) on-demand symptom reporting using a modified version of the Edmonton Symptom Assessment Score (ESAS-r-CS [ 25 ]) via an app-based interface downloaded on the participant’s personal smartphone device, (4) a PC self-referral prompted via the study app, and (5) an option to request a phone call from their oncology team within 3 days to discuss their symptoms. Online content introducing patients to PC included the CAPC definition of PC (“specialized medical care for people living with a serious illness”), the embedded video “Palliative Care: YOU Are a Bridge” (1 minute, 43 seconds), and a description of PC’s role in symptom management and goal concordant care [ 17 ]. Patients also received the CAPC printed handout, “Palliative Care: What You Should Know” , which included curated answers to seven frequently asked questions about PC [ 26 ]. Participants were counseled to use the app as often as desired over 6 months. With each app use, participants reported their symptoms via an ESAS-r-CS survey [ 25 ], followed by a yes/no prompt, “Do you want to see a palliative care specialist at your next oncology visit?” , and a multi-option list with free text fields where they could indicate their rationale for requesting or declining PC. When PC was requested, a referral order was routed to and signed by the oncology team in the electronic health record (EHR). While oncology clinicians could decline a request for PC referral, this was not observed in the parent study. Symptom scores were then forwarded to an outpatient PC physician, and the patient was contacted by clinic staff to confirm that the PC physician would see them during their next oncology appointment. Finally, the app then delivered a second yes/no prompt, “Do you want a member of the oncology team to contact you within the next 3 days to discuss your symptoms?” . The patient’s symptom scores (ESAS-r-CS [ 25 ]) were forwarded to the oncology team only when “yes” was selected for this prompt, and an oncology clinic nurse called the patient to obtain more information about their symptoms. The nurse documented the patient’s concerns in the EHR and relayed this information to the oncology nurse practitioner, who then offered recommendations for symptom evaluation and treatment, if necessary. Development of interview guide The research team developed a semi-structured interview guide to explore participants’ perspectives on feasibility and acceptability of each SyMPLER intervention component and elicit suggestions for improvement (see Supplemental Materials). If a participant requested PC or oncology team callback after their initial qualitative interview, they were contacted to complete a second interview about their experience of requesting help through the SyMPLER app. Data collection Interviews were conducted from May 2024 to May 2025. Participant contact information and demographics were collected per the SyMPLER study protocol. One member of the research team (J.L.E.) conducted interviews by telephone using the semi-structured interview guide. All interviews were audio recorded, transcribed verbatim, and de-identified. Data analysis Interview transcripts were coded using a preliminary coding dictionary based on questions in the semi-structured interview guide using ATLAS.ti version 25.0.1 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). Deductive dominant thematic analysis [ 27 , 28 ] allowed for categorization of data across interviews to characterize patient experiences while participating in the SyMPLER intervention. A research team member (A.A.G.) and the senior qualitative researcher (A.S.M.) met regularly to discuss the application of codes. Five members of the research team met monthly to discuss the coded data and analysis. Subsequent group discussion informed the refinement of code definitions and the addition of emergent codes. Questions about application of the codes were resolved by team consensus. This work follows the Standards for Reporting Qualitative Research [ 29 ]. Results Sixty patients were approached for participation in semi-structured interviews, which represented 63.8% of participants enrolled in the SyMPLER parent study. Of the 31 who consented to interviews, 21 participants had high engagement with the study app whereas 10 participants had low engagement prior to being interviewed. Individual interviews lasted an average of 20 minutes. Patient-reported reasons for declining interview participation are provided in Fig. 2 . Participant characteristics Most interviewees were female (67.7%), white (93.5%), married (77.4%), and had private health insurance (67.7%, Table 1 ). Compared to the low engagement cohort, participants in the high engagement cohort tended to be younger (median age: 60 vs 64 years), have a college degree (38.1% vs 10.0% of cohort), and live farther from the thoracic oncology clinic (median distance: 68.0 vs 19.4 miles). Twenty-six interviewees (83.9%) used the app at least once and were exposed to all components of the SyMPLER intervention. Five interviewees (16.1%) requested PC via the study app, of which two patients in the high engagement cohort self-referred to PC after completing their initial interview. Four participants (12.3%) used the app to request a telephone call from their oncology team to discuss symptom management. Table 1: SyMPLER Qualitative Study Patient Demographics High Engagement (n = 21) Low Engagement (n = 10) Age , median (IQR) 60 (51, 67) 64 (58, 70) Female sex , n (%) 15 (71.43) 6 (60.00) Race , n (%) White Black Asian 19 (90.48) 1 (4.76) 1 (4.76) 10 (100.00) -- -- Marital Status , n (%) Married Domestic Partner Widowed Divorced Single 16 (76.19) -- 1 (4.76) 2 (9.52) 2 (9.52) 8 (80.00) -- -- 1 (10.00) 1 (10.00) Education , n (%) High school Some college Technical school Undergraduate degree Advanced degree 5 (23.81) 8 (38.10) -- 2 (9.52) 6 (28.57) 3 (30.00) 4 (40.00) 2 (20.00) -- 1 (10.00) Distance to clinic (mi) , median (IQR) 68.00 (37.20, 95.90) 19.35 (11.30, 52.40) Insurance type , n (%) Medicare Medicaid Private Medicare + Private 6 (28.57) -- 13 (61.90) 2 (9.52) 4 (40.00) -- 6 (60.00) -- SyMPLER feasibility and acceptability Table 2 presents representative quotes about overall feasibility and acceptability of the SyMPLER intervention, by cohort. Most participants in the high engagement cohort shared positive perspectives about the SyMPLER intervention, stating that it was “simple”, “easy to use”, and “a really good thing”. Participants in the low engagement cohort also stated that the app was “easy” and “user friendly” while citing low symptom burden, technology concerns (“I am electronically difficult”), and time constraints (“we just didn’t have the time”) as the main feasibility barriers. Three months after enrolling in the SyMPLER study, one participant in the low engagement cohort requested help from the research staff to teach him how to navigate the app, which improved his ability to report symptoms: Table 2 Feasibility and Acceptability of the SyMPLER Intervention High engagement Low engagement Feasibility “It’s very easy. I mean very super easy to use, fast…I love the reminders every week to get in there, the text reminder. And I mean it's again, it's just super easy and fast. It only takes five minutes to go through and run through the questions really fast. So, I think it's been a good experience.” (13) ‬‬ “It’s super simple, it doesn’t take much time. Yeah. That’s about it. I just- the reminders help. So, I get those reminders every week and just the fact that it doesn't take long to fill out the symptoms. I like that it's an easy pick on the scale and you don’t have to necessarily put in verbiage if you don't want to. But there's an opportunity, I think at the end to do that.” (30) ‬‬ “You mean that thing I can’t get into? Well, I don't know because I can't get into it. I don't- yeah, I just don't know how to use it. I don't even know if it's on my phone. Yeah, it is on my phone, but I don't know if they want a login or something that I don't have, I'm not sure... I should probably use it. Yeah. If it helps with symptoms, yeah, I’m glad to do it. (17) ‬‬‬‬‬‬‬‬ “It, for me and my age, I find it difficult to read that much. The font is kind of small, so it makes it a little bit more difficult. Probably in hindsight, it would have been better to maybe watch- to have it on a tablet, an iPad, or something that is a bit bigger. But I don't carry one of those around with me all the time.” (39) ‬‬ Acceptability “I like it. It's very easy. It’s not a hindrance to me being out and about my day, anything like that. ” (3) I think it's nice, concise, easy to use. It doesn't take up much time. It’s nice and easy to use. I like that you guys text me a reminder if I don’t remember to do it. (19) “So, I think for me, if I were to start having more symptoms, I probably would want to track it a little bit more. But because I'm not really having symptoms, I was kind of like, I don't really need to go in and log anything, because I don't really have anything to log. ” (32) “Well, I didn't use it. I didn't have any what I would think of as extreme symptoms that I thought I needed a specialist for… So, why bother to go to an app when I can just call and get an answer pretty quickly? And if I need some kind of help, they can get it for me. And they did.” (34) “I thought it was excellent. The only problem I had, which was my fault, not knowing until I learned, not knowing how to get in there and do the thing, fill out the questionnaires and all that stuff. That was my fault, not SyMPLER’s. Somebody from the clinic helped me out with it. I did not know that that icon, it said SyMPLER on it was you guys. And then she helped me out and she got the icon on my cell phone and begin filling it out pretty good.” (17, second interview)‬‬ Impressions of SyMPLER Components Participants shared their impressions about each component of SyMPLER (Table 3 ). Many participants in both cohorts reported difficulty remembering details of the online and printed educational materials that introduced PC upon study enrollment (“I don’t even know what that is. Palliative care.”). Some participants in the high engagement cohort reported they understood PC better after viewing the educational materials (“it completely changed my view”); others reflected on their prior exposures to PC (“I had several family members that were in it”). While most participants in the low engagement cohort had little or no recollection of the educational materials, one participant reported strong emotions after viewing the website about PC: Table 3 Impressions of SyMPLER Components Component High engagement cohort Low engagement cohort Introduction to palliative care (online + print) “I think, like I said, the website was very simplistic. And I think the paper went a little bit more in depth. So that if you had questions, or didn’t quite understand something, or this was a completely new and foreign topic to you, you could look back at it and be able to get more questions answered on there.” (19) “I think the things I learned from the reading, whether it was the website or the handout, I can't remember. But, were just things I hadn't thought about in addition to pain. I mean, I hadn’t really thought about things like appetite and constipation, depression and anxiety. I hadn't really thought about those things as being something that palliative care would address. So, just seems to me there's more to it than what I ever realized before. ” (25) “I really don't remember. I kind of knew about palliative care, like I said, from my sister, and what she does for a living. But other than that, I don't really remember the website. ” (7) “We used that print out thing. I really can't tell you or explain it to you. Yes, my sister explained it to me. She explained what the piece of paper was telling us. ” (12) ‬‬‬‬‬‬ Weekly SMS text reminders “I appreciate the text reminder every Monday. Having a notification is great and having it at the same time, same day is also good.” (31) ‬‬ The text notification is perfect. As soon as I get it, I pin it to the top of my texts to remind myself to make sure I do it. So, no, that's perfect. (35) “It was nice to have the reminders come. Oh, your survey is due, please answer it as soon as you can, or whatever. I didn’t feel pressured to do any of it, but. And like I said, I had very few symptoms, so there was really nothing to say. ” (7) “I think mentally it was a little bit draining… I think when you're going through it [cancer], it's kind of nice to have a break from thinking about it. Maybe that's a little bit why when it popped up as reminder, it was kind of like, ‘Oh, I don't really want to think about this right now.’” (32) On-demand symptom reporting via study app “It was pretty easy, I mean there wasn’t a lot of questions, so. ” (10) “I think giving me a scale from 0 to 10, it's helpful for me to easily choose. And also display pain, no pain, worst possible pain. Let me understand how the scale works is making it very easy to select. So I can just take click on number. And also, I can even skip this question if I prefer not to answer. That's helpful.” (31) “I used my cell phone. Yeah. I am pretty efficient with the computers and stuff, so. Using a cellphone or whatever to answer the questions is again, easy. And I didn’t have any issues with any of it. Click and go. Click your answers down if there’s anything you need to spell out, you could. There’s plenty of area for that. Not just yes or no. And if you need to spell out something you could put down whatever symptoms you were having. And that was pretty well, easy to use .” (7) ‬‬ “Yes, I did use it. I know I did once, and I'm not sure if the second time it took or went through…And then afterwards, I just thought I’m not even doing this anymore.” (41) Prompted option for palliative care self-referral “I thought it was okay, but I haven't had to request that yet. Well, I like that the option is out there if I needed it. So, it's just good to know that it's there and in the background and available to me if I should need it. ” (24) ‬‬ “Yeah, I think that’s good because I think it’s a very- to me it seems like a personal choice that somebody has to make. And I do think that you never know when somebody might get to that position that they feel like they need that extra assistance. So, having the access to do that. I mean, some people might feel like they have to wait until their next appointment or till the doctor suggests it. So, I think it’s nice to kind of, I don’t know, arm your patients with the tools that they need and know that they don’t have to go through their doctor or wait on an appointment but that’s something they can reach out to when they need it.” (30) “Well, I supposed if I’d had more symptoms or something, I would have requested that, but. Like I said, I never even got so much as nauseous after my treatments and stuff. So, I really didn't think I needed much palliative care.” (7) “I think that's good. Did I request one? No. Well, if I do, I would use OSU MyChart and send a message to palliative care. ” (12) ‬‬ Prompted option for oncology team contact “I have not because at least at this point in the trial, I'm down there every single week already anyway. So, I'm discussing symptoms when I'm there. I think it's great because, like I said, sometimes going through the regular channels or trying to figure out how do I log into the portal and message my doctor. If this is somebody that's a brand-new patient, those things often can be daunting. ” (19) ‬‬ “I think honestly, if something came up that I feel like I needed to reach out to my doctor, I would probably just call in at the office. That would be my first gut reaction. ” (30) “I call. If I don't call, well, I’ve had several times I needed information or something. And I every time I called…I went straight to the source. I called the doctor's office. ” (34) “I have done that in MyChart. But not on the SyMPLER app.” (39) “I think that was pretty emotional for both of us… really the only thing kind of we knew about palliative care was more like end-of-life type care is sort of what we had in mind and so, it was a little bit, I don't know. It was a lot to watch the video, to be honest, because it was kind of like preparing for kind of a worst-case scenario is how it felt in moment.” (32) Most participants voiced positive opinions about the weekly text reminders with some participants suggesting customization of the frequency, modality (e.g., push notifications), and day/time when reminders were sent. Participants who reported symptoms through the study app stated that the ESAS-r-CS survey was “simple”, “convenient”, and “pretty straight-forward”. Two low engagement participants cited technology concerns (“not being good at touching letters on a cell phone”) as a limitation to completing the ESAS-r-CS questionnaire via an app interface. Participants endorsed the PC self-referral as “a real good option”, although only five interviewees ( 3 high engagement; 2 low engagement) responded “yes” to this prompt. Participants cited low symptom burden (“I'm not having any symptoms whatsoever”) and insufficient knowledge of PC (“I didn’t understand what it was”) as main reasons for declining a PC referral. Participants in both cohorts reflected that PC may be beneficial for “other people” while appreciating the direct access to PC via self-referral. One high-engagement participant described how SyMPLER facilitated her PC self-referral: “So, all along it was like, oh, there isn't really anything bad enough about what I'm going through to require this. But then I ended up having another surgery, and things went badly wrong and to the point where, I'm in a wheelchair now, and having a lot of pain from that. And that's when I asked for the palliative specialist… I mean, it made it very easy. Honestly, if I didn't have that on the app, I'm not sure I would have made the phone call. So, that was great. ” (25, second interview) Participants also noted acceptability of the option to request contact from their oncology team to discuss symptoms (“real helpful”) although only four participants opted for this option. Several participants voiced preference for contacting their oncology team via telephone or patient portal (e.g., MyChart) connected to the EHR. Suggestions for program improvement Participants in both cohorts provided feedback on how to improve SyMPLER (Table 4 ). One participant asked for a “refresher” on the education materials about PC. Participants suggested ways to make SyMPLER “more patient-centric” such as adding additional free text fields where patients could describe symptoms “in their own words”. Several participants also expressed a desire to view reports or trends of their prior ESAS responses to enable them to choose a score based on whether a symptom was better/worse than the previous day/week. To better integrate symptom reporting into their daily lives, several participants asked for further customization of the frequency (e.g., twice weekly, biweekly) and timing (e.g., day of the week, time of day) of when text reminders were delivered to their smartphone device. Some participants also suggested that a follow-up reminder could be delivered a few days after the weekly text if they forgot to report symptoms in the SyMPLER app. Table 4 Suggestions to Improve the Intervention Cohort Verbatim participant quotations High engagement “I could give a section in there to where actually someone could document how they're feeling in their own words. That might be helpful.” (2) “I don't think with numbers you can fully explain it. I think it needs to be more patient-centric because everybody's different and everybody reacts to it differently. The first time I went through chemo I didn’t feel anything. I really felt it this time. So, I think there's - I think it needs to be a little more in depth.” (10) “It would be more beneficial if there was a way to say, have you experienced any new symptoms this week? And then like whatever you type in, then it'll ask about that specific thing in the future.” (19) “Some of the symptoms it's hard to quantify and I would forget the number I gave last time… So, if I can see what my last score is, it's easy for me to make a judgment, right? Am I getting better or worse? So, I can move the score up or down from last time. (31) Low engagement “I guess the only thing that might help is to be able to explain why this is important. I got more of a feel of we're just studying this app and seeing how it works for people and if you do it, fine, if you don't do it, fine. That's up to you but you'll still be participating as long as you sign up or say you'll do it or whatever. I guess I never got a real sense that it was really important. ” (34) “My recommendation would be to do a follow up reminder. Because it always seems like whatever time I got it, I was not in a position to be able to do it at that time. And then I could just completely forgot about it. For then the next Monday I got one, or it was like the time I'm starting work or something whenever the reminder comes in. And so, it was just not a good time that I could take the time to do it at that- and then I just completely forgot about it. ” (39) Most participants stated that they would recommend SyMPLER to other patients, although their reasons for recommending the program differed by cohort. While participants in the low engagement cohort stated that they would recommend SyMPLER for the purpose of advancing cancer research ( “But any help… we could provide for research purposes, I think is, can only be beneficial” ), highly engaged participants identified how the program could improve patient care: “Well, it gets them connected to the right people when they need help. And I think sometimes with the science part of it, you can slip through it, kind of slip through the cracks a little bit. ” (2) Discussion As a DBCI, SyMPLER encourages patients to report symptoms outside the medical setting via an app-based interface and prompts them to request an oncology clinician callback and/or self-refer to PC specialist when needed for symptom management. For SMPs, DBCIs have the potential benefit of augmenting person-to-person interventions that address patient symptoms or offer PC referral only during clinic appointments. While interviews with participants support overall feasibility and acceptability of SyMPLER, key modifications to the intervention may improve patient engagement with remote symptom reporting and increase their willingness to request help for cancer-related symptoms. In healthcare, the success of a DBCI depends on the patient’s ability and willingness to repeatedly engage with the technology. In this study, patients in both cohorts noted that weekly cues, ease, and low time burden were key factors contributing to the feasibility and acceptability of SyMPLER for remote symptom reporting. Despite its simplicity, technology barriers limited some participants’ abilities to report symptoms through the study app. To address this digital divide, patients may benefit from educational outreach delivered by nursing staff or lay navigators to increase their understanding and engagement with symptom monitoring outside the healthcare setting [ 30 ]. Reminders, delivered via SMS text to a patient’s personal cell phone, increase patient completion of health-related tasks, including cancer screenings [ 31 ], vaccinations [ 32 ], and medical appointments [ 33 ]. Participants in our study noted acceptance of this SyMPLER component and suggested the cues were helpful in reminding them to complete a potentially ignorable task (e.g., logging symptoms). In addition, participants in our study described the need for customization of the day and time when text reminders are sent in order to integrate symptom reporting with competing demands of patients’ daily lives (e.g., returning to work [ 34 ]). Follow-up reminders, delivered if a task remains uncompleted, have been shown to increase completion of annual flu vaccination [ 32 ] and may be another strategy to encourage habitual symptom reporting in future iterations of SyMPLER. In the SyMPLER intervention, we chose the ESAS due to its brevity, use of a numerical visual analog scale, and validation across many languages and cancer diagnoses [ 35 ]. While some SMPs have used ESAS scoring thresholds to drive PC consultation [ 36 , 37 ], others account for intra-subject correlation (e.g., patients who tend to always report below-threshold scores despite bothersome symptoms) by offering PC when symptom scores significantly increase over time (e.g., ≥ 2-point increase in an individual symptom score) [ 38 ]. In SyMPLER, all participants were offered PC upon each ESAS completion regardless of their reported symptom scores. Future integration of symptom-triggered prompts suggesting a PC self-referral or oncology callback when symptom scores increase or exceed predefined thresholds may inform patients about when to seek help for bothersome symptoms. Self-referral allows patients to choose whether and when to access PC for symptom management. While patients in both cohorts noted acceptance of the self-referral prompt, few could recall details about the education materials introducing PC upon study enrollment. Echoing a smaller pilot study of an SMP that prompted patients to schedule a PC appointment [ 39 ], lack of understanding about PC may be a contributing factor to why most participants did not request a consultation through the SyMPLER study app. As healthcare providers struggle with when and why to refer patients to specialty PC [ 40 ], our study demonstrates that patients face similar uncertainty when prompted to consider a PC self-referral. By equipping an SMP with opportunities for patients to seek help, SyMPLER captures information on how a patient is feeling when they request a PC consultation. Precision PC is a framework for care delivery aimed at connecting the most symptomatic patients with specialty PC [ 41 , 42 ]. Unlike early PC guidelines that rely on disease-focused referral criteria [ 43 ], precision PC advocates for the use of patient-reported outcomes (PROs) to trigger an initial consultation [ 36 , 37 ] or longitudinal follow-up with an interdisciplinary PC team [ 44 ]. However, there is little consensus on PRO-based referral criteria for PC. Combined with PROs, self-referral may be the most precise indicator of a patient’s need and willingness to seek help from specialty PC. In this initial iteration, SyMPLER integrates PROs with self-referral to specialty PC in a way that patients report is both feasible and acceptable after a new lung cancer diagnosis. This study has several limitations. First, we only interviewed participants exposed to the SyMPLER intervention. We may have heard more diverse perspectives about remote symptom monitoring, particularly related to technology barriers, if we had interviewed patients who declined SyMPLER enrollment due to technological concerns or lack of interest. Second, few interviewees opted for a PC self-referral, which limited our ability to ascertain why patients seek PC and whether these reasons fit within the current referral criteria recommended by consensus guidelines. Although there is a lack of racial and ethnic diversity in our study population, there is good representation across different levels of education, insurance payer source, and residential proximity to the cancer center. Females are overrepresented, which is reflected by a higher proportion of women enrolled in the SyMPLER parent study. Conclusion In this qualitative study, most participants were willing and able to remotely report cancer-related symptoms through the SyMPLER intervention. Most patients noted acceptance of the option to self-refer to PC, although few sought a PC consultation during the intervention period. Like clinicians, patients struggle with when and why to pursue a PC consultation. Patients’ suggestions to improve the SyMPLER intervention may help to increase patient engagement with remote symptom reporting and PC self-referral in future studies. Declarations Funding: This work was funded through a Junior Investigator Award from The Ohio State University Department of Internal Medicine and a Young Investigator Award from the National Comprehensive Cancer Network Foundation. Salary support for Dr. Merlin is funded through a K24 award from the National Institute on Drug Abuse (K24DA056837). Salary support for Dr. Presley is funded through the K76 Paul B. Beeson Emerging Leaders Career Development Award in Aging from the National Institute on Aging (K76AG074923). Author Contribution J.L.A. conceptualized the project, designed the study, interpreted results, and wrote the draft manuscript. A.A.G. and A.S.M. developed the codebook for qualitative interviews. L.J.R. and A.S. cleaned interview transcripts. J.L.E. completed all participant interviews. M.M.G. supervised data collection and managed the IRB and regulatory tasks related to the project. J.S.M., J.S., and C.J.P. contributed to the study design and contributed critical review and editing of the manuscript. A.S.M. supervised qualitative analysis and study design throughout all stages, and provided critical revisions of the manuscript. Data Availability De-identified interview transcripts and codebooks can be shared upon written request to the corresponding author under a data-sharing agreement that provides for: i) a commitment to using the data only for research purposes and not to identify any individual participant, ii) a commitment to securing the data using appropriate computer technology; and iii) a commitment to destroying or returning the data after analyses are completed. References Webber, K., et al., Symptom prevalence and severity in palliative cancer medicine . BMJ Support Palliat Care, 2023. 13(e2): p. e270-e272. Dong, S.T., et al., Symptom clusters in patients with advanced cancer: a systematic review of observational studies . J Pain Symptom Manage, 2014. 48(3): p. 411–50. Simao, D., et al., Symptom Clusters in Patients With Advanced Cancer: A Prospective Longitudinal Cohort Study to Examine Their Stability and Prognostic Significance . Oncologist, 2024. 29(1): p. e152-e163. Astrup, G.L., et al., Patient factors and quality of life outcomes differ among four subgroups of oncology patients based on symptom occurrence . Acta Oncol, 2017. 56(3): p. 462–470. Walling, A.M., et al., Symptom prevalence in lung and colorectal cancer patients . J Pain Symptom Manage, 2015. 49(2): p. 192–202. McLouth, L.E., et al., Palliative care use and utilization determinants among patients treated for advanced stage lung cancer care in the community and academic medical setting . Support Care Cancer, 2023. 31(3): p. 190. Denis, F., et al., Two-Year Survival Comparing Web-Based Symptom Monitoring vs Routine Surveillance Following Treatment for Lung Cancer . JAMA, 2019. 321(3): p. 306–307. Basch, E., et al., Overall Survival Results of a Trial Assessing Patient-Reported Outcomes for Symptom Monitoring During Routine Cancer Treatment . JAMA, 2017. 318(2): p. 197–198. Basch, E., et al., Symptom Monitoring With Patient-Reported Outcomes During Routine Cancer Treatment: A Randomized Controlled Trial . J Clin Oncol, 2016. 34(6): p. 557–65. Temel, J.S., et al., Early palliative care for patients with metastatic non-small-cell lung cancer . N Engl J Med, 2010. 363(8): p. 733–42. Gast, K.C., et al., Impact of an Embedded Palliative Care Clinic on Healthcare Utilization for Patients With a New Thoracic Malignancy . Front Oncol, 2022. 12: p. 835881. Hassett, M.J., et al., eSyM: An Electronic Health Record-Integrated Patient-Reported Outcomes-Based Cancer Symptom Management Program Used by Six Diverse Health Systems . JCO Clin Cancer Inform, 2022. 6: p. e2100137. Basch, E., et al., Effect of Electronic Symptom Monitoring on Patient-Reported Outcomes Among Patients With Metastatic Cancer: A Randomized Clinical Trial . JAMA, 2022. 327(24): p. 2413–2422. Finney Rutten, L.J., et al., Pragmatic cluster randomized trial to evaluate effectiveness and implementation of enhanced EHR-facilitated cancer symptom control (E2C2) . Trials, 2020. 21(1): p. 480. Kroenke, K., et al., Incorporating PROMIS Symptom Measures into Primary Care Practice-a Randomized Clinical Trial . J Gen Intern Med, 2018. 33(8): p. 1245–1252. Minteer, S.A., et al., Implementing cancer symptom management interventions utilizing patient-reported outcomes: a pre-implementation evaluation of barriers and facilitators . Support Care Cancer, 2023. 31(12): p. 697. Lyn Ceronsky, A.E., Nathan Goldstein, Jay R. Horton, Khaliah Johnson, Tammy I. Kang, Anna Loengard, Joan Panke, Beth Popp, Randall Schisler. Get Palliative Care . 16 January 2025]; Available from: www.getpalliativecare.org. Penedo, F.J., et al., Implementation and Feasibility of an Electronic Health Record-Integrated Patient-Reported Outcomes Symptom and Needs Monitoring Pilot in Ambulatory Oncology . JCO Oncol Pract, 2022. 18(7): p. e1100-e1113. Tan, I. and K. Ramchandran, The role of palliative care in the management of patients with lung cancer . Lung Cancer Manag, 2020. 9(4): p. LMT39. Kuo, J.C., et al., A randomized trial of the electronic Lung Cancer Symptom Scale for quality-of-life assessment in patients with advanced non-small-cell lung cancer . Curr Oncol, 2020. 27(2): p. e156-e162. Parikh, R.B., et al., Remote Patient-Reported Outcomes and Activity Monitoring to Improve Patient-Clinician Communication Regarding Symptoms and Functional Status: A Randomized Controlled Trial . JCO Oncol Pract, 2023. 19(12): p. 1143–1151. Zhu, Y., et al., Digital Behavior Change Intervention Designs for Habit Formation: Systematic Review . J Med Internet Res, 2024. 26: p. e54375. Sunstein, C.R., The Council of Psychological Advisers . Annu Rev Psychol, 2016. 67: p. 713–37. Saunders, B., et al., Saturation in qualitative research: exploring its conceptualization and operationalization . Qual Quant, 2018. 52(4): p. 1893–1907. Hannon, B., et al., Modified Edmonton Symptom Assessment System including constipation and sleep: validation in outpatients with cancer . J Pain Symptom Manage, 2015. 49(5): p. 945–52. Lyn Ceronsky, N.G., Jay R. Horton, Khaliah Johnson, Tammy I. Kang, Anna Loengard, Joan Panke, Beth Popp, Randall Schisler. Palliative Care Patient Education Handouts . 11 July 2025]; Available from: https://getpalliativecare.org/handouts-for-patients-and-families/ . Willig, C., The Sage handbook of qualitative research in psychology, 2e . 2nd edition. ed. 2017, Thousand Oaks, CA: SAGE Inc. pages cm. Vaismoradi, M., H. Turunen, and T. Bondas, Content analysis and thematic analysis: Implications for conducting a qualitative descriptive study . Nurs Health Sci, 2013. 15(3): p. 398–405. O'Brien, B.C., et al., Standards for reporting qualitative research: a synthesis of recommendations . Acad Med, 2014. 89(9): p. 1245–51. McAlearney, A.S., et al., Effect of In-Person vs Video Training and Access to All Functions vs a Limited Subset of Functions on Portal Use Among Inpatients: A Randomized Clinical Trial . JAMA Netw Open, 2022. 5(9): p. e2231321. Huf, S., et al., Behavioral economics informed message content in text message reminders to improve cervical screening participation: Two pragmatic randomized controlled trials . Prev Med, 2020. 139: p. 106170. Milkman, K.L., et al., A 680,000-person megastudy of nudges to encourage vaccination in pharmacies . Proc Natl Acad Sci U S A, 2022. 119(6). Werner, K., et al., Behavioural economic interventions to reduce health care appointment non-attendance: a systematic review and meta-analysis . BMC Health Serv Res, 2023. 23(1): p. 1136. Butow, P., et al., Return to work after a cancer diagnosis: a meta-review of reviews and a meta-synthesis of recent qualitative studies . J Cancer Surviv, 2020. 14(2): p. 114–134. Hui, D. and E. Bruera, The Edmonton Symptom Assessment System 25 Years Later: Past, Present, and Future Developments . J Pain Symptom Manage, 2017. 53(3): p. 630–643. Zimmermann, C., et al., Symptom screening with Targeted Early Palliative care (STEP) versus usual care for patients with advanced cancer: a mixed methods study . Support Care Cancer, 2023. 31(7): p. 404. Zimmermann, C., et al., Phase II Trial of Symptom Screening With Targeted Early Palliative Care for Patients With Advanced Cancer . J Natl Compr Canc Netw, 2021. 20(4): p. 361–370 e3. Patel, M.I., et al., Association of a Lay Health Worker Intervention With Symptom Burden, Survival, Health Care Use, and Total Costs Among Medicare Enrollees With Cancer . JAMA Netw Open, 2020. 3(3): p. e201023. Kaufmann, T.L., et al., Feasibility Study of Using Electronic Patient-Reported Outcomes to Screen Patients with Advanced Solid Cancers for Palliative Care Needs . J Palliat Med, 2025. 28(5): p. 580–591. Enguidanos, S., et al., Health Care Provider Barriers to Patient Referral to Palliative Care . Am J Hosp Palliat Care, 2021. 38(9): p. 1112–1119. Sedhom, R., L.N. Shulman, and R.B. Parikh, Precision Palliative Care as a Pragmatic Solution for a Care Delivery Problem . J Clin Oncol, 2023. 41(16): p. 2888–2892. Petrillo, L.A. and J.L. Agne, Re-Examining Early in Early Palliative Care: Precedent, Reality, and Future Research Priorities . JCO Oncol Pract, 2025: p. OP2500479. Ferrell, B.R., et al., Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update . J Clin Oncol, 2017. 35(1): p. 96–112. Temel, J.S., et al., Stepped Palliative Care for Patients With Advanced Lung Cancer: A Randomized Clinical Trial . JAMA, 2024. 332(6): p. 471–481. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":45599,"visible":true,"origin":"","legend":"\u003cp\u003eSee image above for figure legend\u003c/p\u003e\n\u003cp\u003eFive components of the SyMPLER intervention in sequential order. Component 1 occurred at study enrollment. SMS text reminders (Component 2) were delivered every Monday at noon during the 6-month intervention period. Participants were counseled to use the study app as often as they desired to report symptoms, self-refer to palliative care, and/or request a telephone call from a thoracic oncology nurse\u0026nbsp; (Components 3-5).\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1 \u003c/sup\u003eAvailable at: https://getpalliativecare.org/whatis\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e \u003cem\u003ePrompt:\u003c/em\u003e Do you want to see a palliative care specialist at your next oncology visit?\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e3 \u003c/sup\u003e\u003cem\u003ePrompt:\u003c/em\u003e Do you want a member of the medical team to contact you within the next 3 days to discuss your symptoms?\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7420494/v1/619a41444f6f160073b01578.png"},{"id":95669309,"identity":"cf8eed39-c929-4d7f-8cbe-c796e24a0c90","added_by":"auto","created_at":"2025-11-11 17:10:15","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":183271,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRecruitment Consort diagram\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e Represents 63.8% of SyMPLER pilot study target enrollment.\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e2\u003c/sup\u003e Enrollment was declined by a caregiver on behalf of the patient.\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7420494/v1/6c4af93251e5dd806e018792.png"},{"id":96367110,"identity":"cc06b8e7-9522-4619-a288-f5d5942c90f2","added_by":"auto","created_at":"2025-11-20 10:12:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1175926,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7420494/v1/178920e3-057a-4822-812d-fa3029419563.pdf"},{"id":95669302,"identity":"5df3ea1d-6334-4d00-97a3-7504f3da3f7a","added_by":"auto","created_at":"2025-11-11 17:10:15","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":19092,"visible":true,"origin":"","legend":"","description":"","filename":"SyMPLERInterviewGuide.docx","url":"https://assets-eu.researchsquare.com/files/rs-7420494/v1/9015e0af50d7996ceaa5723c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"SyMPLER Palliative Care: a qualitative study of patient experiences with a symptom monitoring program and self-referral to specialty palliative care","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMost patients report at least one uncontrolled symptom (e.g. pain, nausea, anxiety) after a cancer diagnosis [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Symptoms often fluctuate during an individual\u0026rsquo;s cancer trajectory [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and this can impact patients\u0026rsquo; health-related quality of life (HRQOL) and cancer-related survival [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. For example, thoracic malignancies are highly symptomatic, with \u0026gt;\u0026thinsp;90% of patients reporting at least one bothersome symptom [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Among patients with metastatic non-small cell lung cancer (NSCLC), fatigue, insomnia, and dyspnea predominate during systemic cancer treatment while pain increases with disease progression and declining performance status [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Therefore, early symptom identification and treatment can be crucial to improve patient experiences and outcomes during cancer care.\u003c/p\u003e\u003cp\u003eTwo evidence-based approaches \u0026ndash; symptom monitoring programs (SMPs) and specialty palliative care (PC) \u0026ndash; have independently been shown to improve HRQOL, reduce healthcare utilization, and prolong survival through identification and treatment of cancer-related symptoms [\u003cspan additionalcitationids=\"CR8 CR9 CR10\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In SMPs, patients systematically report cancer symptoms via a digital interface (e.g., tablet, computer, smartphone device) to their oncology clinicians who can then address uncontrolled symptoms between clinic visits [\u003cspan additionalcitationids=\"CR13\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. SMPs rely on clinician response to patient-reported symptoms as symptom reporting alone is non-superior to usual care [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In contrast to a digital reporting approach, PC uses an interdisciplinary team of specialty-trained physicians, advanced practice providers, and nurses to address cancer-related distress with a particular focus on symptom management [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. As SMPs rely on the responsiveness and primary symptom management skills of oncology clinicians [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], prior SMPs have not impacted patient receipt of specialty PC, despite high patient-reported symptom burden [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Integration of PC into SMPs remains a unique opportunity to improve patients\u0026rsquo; cancer-related symptoms.\u003c/p\u003e\u003cp\u003eTo advance the science of SMPs, we developed SyMPLER: \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSy\u003c/span\u003emptom \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eM\u003c/span\u003eonitoring \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eP\u003c/span\u003erogram \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eL\u003c/span\u003einked to \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eE\u003c/span\u003electronic \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eR\u003c/span\u003eeferrals. To our knowledge, SyMPLER is the first digital behavioral change intervention (DBCI) that integrates PC into an SMP via a mobile health (mHealth) application (app). DCBIs deliver cues to encourage a particular behavior, accompanied by positive reinforcement to encourage the continuation of the behavior over time [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The SyMPLER DCBI delivers weekly cues via text reminders that encourage patients to self-report the severity of their cancer-related symptoms. It also allows patients to request and then receive help, a form of positive reinforcement, via two means: oncology clinician callback and/or PC self-referral. An option for oncology callback and palliative care self-referral within an SMP represents an important innovation: it has the potential to improve access to specialty PC in a highly patient-centered way through symptom self-assessment and allowing the patient to decide whether and when to seek PC. Using principles from behavioral economics [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], SyMPLER prompts patients to make active choices about seeking help while minimizing logistical barriers (e.g., \u003cem\u003e\u0026ldquo;Do you want to see a palliative care specialist at your next oncology visit?\u0026rdquo;; \u0026ldquo;Do you want a member of the oncology team to contact you?\u0026rdquo;\u003c/em\u003e).\u003c/p\u003e\u003cp\u003eThe primary aim of this qualitative study is to explore patients\u0026rsquo; perspectives about the feasibility and acceptability of SyMPLER. Findings from this study can inform future efforts to test and if effective, implement SyMPLER in oncology settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e This study was approved by the Institutional Review Board at The Ohio State University in Columbus, Ohio, USA, and was conducted in accordance with the Declaration of Helsinki.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eSample selection and recruitment\u003c/h2\u003e\u003cp\u003e Participants were recruited from the SyMPLER parent study (NCT06396598), a prospective single-arm feasibility study of SyMPLER in patients with lung cancer. Lung cancer was chosen as the target of SyMPLER due to its high symptom burden across all cancer stages during the first 6 months after diagnosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The SyMPLER parent study included adults (\u0026ge;\u0026thinsp;18 years old) with any stage thoracic malignancy (non-small cell lung cancer, small cell lung cancer, mesothelioma, or thymic carcinoma) who were within 12 weeks of their first outpatient oncology appointment at this National Cancer Institute Comprehensive Cancer Center. Participants were required to have access to a smartphone device and speak and read English; individuals who had been referred to outpatient PC prior to study enrollment were excluded. Parent study participants were approached consecutively via email for qualitative interviews after meeting eligibility criteria, which were 3 instances of using the study app for symptom reporting or at 3 months after enrollment in the SyMPLER study, whichever occurred first. Three follow-up attempts could be made via telephone, and verbal consent was obtained at the beginning of each interview. Participants who consented for qualitative interviews were categorized based on their SyMPLER use: the \u0026ldquo;high engagement\u0026rdquo; cohort used SyMPLER\u0026thinsp;\u0026ge;\u0026thinsp;3 times whereas the \u0026ldquo;low engagement\u0026rdquo; cohort used SyMPLER\u0026thinsp;\u0026lt;\u0026thinsp;3 times within 3 months after enrollment. Recruitment for interviews ended when thematic saturation was achieved [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Participants received a \u003cspan\u003e$\u003c/span\u003e25 gift card following the interview.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSyMPLER symptom monitoring program\u003c/h3\u003e\n\u003cp\u003eThe SyMPLER intervention included five main components (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e): (1) an introduction to PC via online and print educational materials curated by the Center for the Advancement of Palliative Care (CAPC) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], (2) weekly secure messaging system (SMS) text reminders encouraging participants to report symptoms, (3) on-demand symptom reporting using a modified version of the Edmonton Symptom Assessment Score (ESAS-r-CS [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]) via an app-based interface downloaded on the participant\u0026rsquo;s personal smartphone device, (4) a PC self-referral prompted via the study app, and (5) an option to request a phone call from their oncology team within 3 days to discuss their symptoms. Online content introducing patients to PC included the CAPC definition of PC (\u0026ldquo;specialized medical care for people living with a serious illness\u0026rdquo;), the embedded video \u0026ldquo;Palliative Care: YOU Are a Bridge\u0026rdquo; (1 minute, 43 seconds), and a description of PC\u0026rsquo;s role in symptom management and goal concordant care [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Patients also received the CAPC printed handout, \u003cem\u003e\u0026ldquo;Palliative Care: What You Should Know\u0026rdquo;\u003c/em\u003e, which included curated answers to seven frequently asked questions about PC [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eParticipants were counseled to use the app as often as desired over 6 months. With each app use, participants reported their symptoms via an ESAS-r-CS survey [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], followed by a yes/no prompt, \u003cem\u003e\u0026ldquo;Do you want to see a palliative care specialist at your next oncology visit?\u0026rdquo;\u003c/em\u003e, and a multi-option list with free text fields where they could indicate their rationale for requesting or declining PC. When PC was requested, a referral order was routed to and signed by the oncology team in the electronic health record (EHR). While oncology clinicians could decline a request for PC referral, this was not observed in the parent study. Symptom scores were then forwarded to an outpatient PC physician, and the patient was contacted by clinic staff to confirm that the PC physician would see them during their next oncology appointment. Finally, the app then delivered a second yes/no prompt, \u003cem\u003e\u0026ldquo;Do you want a member of the oncology team to contact you within the next 3 days to discuss your symptoms?\u0026rdquo;\u003c/em\u003e. The patient\u0026rsquo;s symptom scores (ESAS-r-CS [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]) were forwarded to the oncology team only when \u0026ldquo;yes\u0026rdquo; was selected for this prompt, and an oncology clinic nurse called the patient to obtain more information about their symptoms. The nurse documented the patient\u0026rsquo;s concerns in the EHR and relayed this information to the oncology nurse practitioner, who then offered recommendations for symptom evaluation and treatment, if necessary.\u003c/p\u003e\n\u003ch3\u003eDevelopment of interview guide\u003c/h3\u003e\n\u003cp\u003eThe research team developed a semi-structured interview guide to explore participants\u0026rsquo; perspectives on feasibility and acceptability of each SyMPLER intervention component and elicit suggestions for improvement (see Supplemental Materials). If a participant requested PC or\u003c/p\u003e\u003cp\u003eoncology team callback after their initial qualitative interview, they were contacted to complete a second interview about their experience of requesting help through the SyMPLER app.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eInterviews were conducted from May 2024 to May 2025. Participant contact information and demographics were collected per the SyMPLER study protocol. One member of the research team (J.L.E.) conducted interviews by telephone using the semi-structured interview guide. All interviews were audio recorded, transcribed verbatim, and de-identified.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eData analysis\u003c/h2\u003e\u003cp\u003eInterview transcripts were coded using a preliminary coding dictionary based on questions in the semi-structured interview guide using ATLAS.ti version 25.0.1 (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany). Deductive dominant thematic analysis [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e] allowed for categorization of data across interviews to characterize patient experiences while participating in the SyMPLER intervention. A research team member (A.A.G.) and the senior qualitative researcher (A.S.M.) met regularly to discuss the application of codes. Five members of the research team met monthly to discuss the coded data and analysis. Subsequent group discussion informed the refinement of code definitions and the addition of emergent codes. Questions about application of the codes were resolved by team consensus. This work follows the Standards for Reporting Qualitative Research [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eSixty patients were approached for participation in semi-structured interviews, which represented 63.8% of participants enrolled in the SyMPLER parent study. Of the 31 who consented to interviews, 21 participants had high engagement with the study app whereas 10 participants had low engagement prior to being interviewed. Individual interviews lasted an average of 20 minutes. Patient-reported reasons for declining interview participation are provided in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\n\u003ch3\u003eParticipant characteristics\u003c/h3\u003e\n\u003cp\u003eMost interviewees were female (67.7%), white (93.5%), married (77.4%), and had private health insurance (67.7%, Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Compared to the low engagement cohort, participants in the high engagement cohort tended to be younger (median age: 60 vs 64 years), have a college degree (38.1% vs 10.0% of cohort), and live farther from the thoracic oncology clinic (median distance: 68.0 vs 19.4 miles). Twenty-six interviewees (83.9%) used the app at least once and were exposed to all components of the SyMPLER intervention. Five interviewees (16.1%) requested PC via the study app, of which two patients in the high engagement cohort self-referred to PC after completing their initial interview. Four participants (12.3%) used the app to request a telephone call from their oncology team to discuss symptom management.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eTable 1: SyMPLER Qualitative Study Patient Demographics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"643\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.1304%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8137%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eHigh Engagement (n = 21)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.0559%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLow Engagement (n = 10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.1304%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e, median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8137%;\"\u003e\n \u003cp\u003e60 (51, 67)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.0559%;\"\u003e\n \u003cp\u003e64 (58, 70)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.1304%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFemale sex\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8137%;\"\u003e\n \u003cp\u003e15 (71.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.0559%;\"\u003e\n \u003cp\u003e6 (60.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.1304%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRace\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;White\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Black\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Asian\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8137%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19 (90.48)\u003c/p\u003e\n \u003cp\u003e1 (4.76)\u003c/p\u003e\n \u003cp\u003e1 (4.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.0559%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10 (100.00)\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.1304%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMarital Status\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Married\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Domestic Partner\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Widowed\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Divorced\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Single\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8137%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e16 (76.19)\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003cp\u003e1 (4.76)\u003c/p\u003e\n \u003cp\u003e2 (9.52)\u003c/p\u003e\n \u003cp\u003e2 (9.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.0559%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e8 (80.00)\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003cp\u003e1 (10.00)\u003c/p\u003e\n \u003cp\u003e1 (10.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.1304%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEducation\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;High school\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Some college\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Technical school\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Undergraduate degree\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Advanced degree\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8137%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e5 (23.81)\u003c/p\u003e\n \u003cp\u003e8 (38.10)\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003cp\u003e2 (9.52)\u003c/p\u003e\n \u003cp\u003e6 (28.57)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.0559%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e3 (30.00)\u003c/p\u003e\n \u003cp\u003e4 (40.00)\u003c/p\u003e\n \u003cp\u003e2 (20.00)\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003cp\u003e1 (10.00)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.1304%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistance to clinic (mi)\u003c/strong\u003e,\u0026nbsp;\u003c/p\u003e\n \u003cp\u003emedian (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8137%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e68.00 (37.20, 95.90)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.0559%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e19.35 (11.30, 52.40)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 39.1304%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eInsurance type\u003c/strong\u003e, n (%)\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Medicare\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Medicaid\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Private\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Medicare + Private\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 29.8137%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6 (28.57)\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003cp\u003e13 (61.90)\u003c/p\u003e\n \u003cp\u003e2 (9.52)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 31.0559%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e4 (40.00)\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003cp\u003e6 (60.00)\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch3\u003eSyMPLER feasibility and acceptability\u003c/h3\u003e\n\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents representative quotes about overall feasibility and acceptability of the SyMPLER intervention, by cohort. Most participants in the high engagement cohort shared positive perspectives about the SyMPLER intervention, stating that it was \u0026ldquo;simple\u0026rdquo;, \u0026ldquo;easy to use\u0026rdquo;, and \u0026ldquo;a really good thing\u0026rdquo;. Participants in the low engagement cohort also stated that the app was \u0026ldquo;easy\u0026rdquo; and \u0026ldquo;user friendly\u0026rdquo; while citing low symptom burden, technology concerns (\u0026ldquo;I am electronically difficult\u0026rdquo;), and time constraints (\u0026ldquo;we just didn\u0026rsquo;t have the time\u0026rdquo;) as the main feasibility barriers. Three months after enrolling in the SyMPLER study, one participant in the low engagement cohort requested help from the research staff to teach him how to navigate the app, which improved his ability to report symptoms:\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFeasibility and Acceptability of the SyMPLER Intervention\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh engagement\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLow engagement\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFeasibility\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;It\u0026rsquo;s very easy. I mean very super easy to use, fast\u0026hellip;I love the reminders every week to get in there, the text reminder. And I mean it's again, it's just super easy and fast. It only takes five minutes to go through and run through the questions really fast. So, I think it's been a good experience.\u0026rdquo; (13) ‬‬\u003c/p\u003e\u003cp\u003e\u0026ldquo;It\u0026rsquo;s super simple, it doesn\u0026rsquo;t take much time. Yeah. That\u0026rsquo;s about it. I just- the reminders help. So, I get those reminders every week and just the fact that it doesn't take long to fill out the symptoms. I like that it's an easy pick on the scale and you don\u0026rsquo;t have to necessarily put in verbiage if you don't want to. But there's an opportunity, I think at the end to do that.\u0026rdquo; (30) ‬‬\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;You mean that thing I can\u0026rsquo;t get into? Well, I don't know because I can't get into it. I don't- yeah, I just don't know how to use it. I don't even know if it's on my phone. Yeah, it is on my phone, but I don't know if they want a login or something that I don't have, I'm not sure... I should probably use it. Yeah. If it helps with symptoms, yeah, I\u0026rsquo;m glad to do it. (17) ‬‬‬‬‬‬‬‬\u003c/p\u003e\u003cp\u003e\u0026ldquo;It, for me and my age, I find it difficult to read that much. The font is kind of small, so it makes it a little bit more difficult. Probably in hindsight, it would have been better to maybe watch- to have it on a tablet, an iPad, or something that is a bit bigger. But I don't carry one of those around with me all the time.\u0026rdquo; (39) ‬‬\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAcceptability\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;I like it. It's very easy. It\u0026rsquo;s not a hindrance to me being out and about my day, anything like that. \u0026rdquo; (3)\u003c/p\u003e\u003cp\u003eI think it's nice, concise, easy to use. It doesn't take up much time. It\u0026rsquo;s nice and easy to use. I like that you guys text me a reminder if I don\u0026rsquo;t remember to do it. (19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;So, I think for me, if I were to start having more symptoms, I probably would want to track it a little bit more. But because I'm not really having symptoms, I was kind of like, I don't really need to go in and log anything, because I don't really have anything to log. \u0026rdquo; (32)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Well, I didn't use it. I didn't have any what I would think of as extreme symptoms that I thought I needed a specialist for\u0026hellip; So, why bother to go to an app when I can just call and get an answer pretty quickly? And if I need some kind of help, they can get it for me. And they did.\u0026rdquo; (34)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I thought it was excellent. The only problem I had, which was my fault, not knowing until I learned, not knowing how to get in there and do the thing, fill out the questionnaires and all that stuff. That was my fault, not SyMPLER\u0026rsquo;s. Somebody from the clinic helped me out with it. I did not know that that icon, it said SyMPLER on it was you guys. And then she helped me out and she got the icon on my cell phone and begin filling it out pretty good.\u0026rdquo;\u003c/em\u003e (17, second interview)‬‬\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eImpressions of SyMPLER Components\u003c/h2\u003e\u003cp\u003eParticipants shared their impressions about each component of SyMPLER (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Many participants in both cohorts reported difficulty remembering details of the online and printed educational materials that introduced PC upon study enrollment (\u0026ldquo;I don\u0026rsquo;t even know what that is. Palliative care.\u0026rdquo;). Some participants in the high engagement cohort reported they understood PC better after viewing the educational materials (\u0026ldquo;it completely changed my view\u0026rdquo;); others reflected on their prior exposures to PC (\u0026ldquo;I had several family members that were in it\u0026rdquo;). While most participants in the low engagement cohort had little or no recollection of the educational materials, one participant reported strong emotions after viewing the website about PC:\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eImpressions of SyMPLER Components\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComponent\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh engagement cohort\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLow engagement cohort\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIntroduction to palliative care (online\u0026thinsp;+\u0026thinsp;print)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;I think, like I said, the website was very simplistic. And I think the paper went a little bit more in depth. So that if you had questions, or didn\u0026rsquo;t quite understand something, or this was a completely new and foreign topic to you, you could look back at it and be able to get more questions answered on there.\u0026rdquo; (19)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think the things I learned from the reading, whether it was the website or the handout, I can't remember. But, were just things I hadn't thought about in addition to pain. I mean, I hadn\u0026rsquo;t really thought about things like appetite and constipation, depression and anxiety. I hadn't really thought about those things as being something that palliative care would address. So, just seems to me there's more to it than what I ever realized before. \u0026rdquo; (25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I really don't remember. I kind of knew about palliative care, like I said, from my sister, and what she does for a living. But other than that, I don't really remember the website. \u0026rdquo; (7)\u003c/p\u003e\u003cp\u003e\u0026ldquo;We used that print out thing. I really can't tell you or explain it to you. Yes, my sister explained it to me. She explained what the piece of paper was telling us. \u0026rdquo; (12) ‬‬‬‬‬‬\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeekly SMS text reminders\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;I appreciate the text reminder every Monday. Having a notification is great and having it at the same time, same day is also good.\u0026rdquo; (31) ‬‬\u003c/p\u003e\u003cp\u003eThe text notification is perfect. As soon as I get it, I pin it to the top of my texts to remind myself to make sure I do it. So, no, that's perfect. (35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;It was nice to have the reminders come. Oh, your survey is due, please answer it as soon as you can, or whatever. I didn\u0026rsquo;t feel pressured to do any of it, but. And like I said, I had very few symptoms, so there was really nothing to say. \u0026rdquo; (7)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think mentally it was a little bit draining\u0026hellip; I think when you're going through it [cancer], it's kind of nice to have a break from thinking about it. Maybe that's a little bit why when it popped up as reminder, it was kind of like, \u0026lsquo;Oh, I don't really want to think about this right now.\u0026rsquo;\u0026rdquo; (32)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOn-demand symptom reporting via study app\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;It was pretty easy, I mean there wasn\u0026rsquo;t a lot of questions, so. \u0026rdquo; (10)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think giving me a scale from 0 to 10, it's helpful for me to easily choose. And also display pain, no pain, worst possible pain. Let me understand how the scale works is making it very easy to select. So I can just take click on number. And also, I can even skip this question if I prefer not to answer. That's helpful.\u0026rdquo; (31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I used my cell phone. Yeah. I am pretty efficient with the computers and stuff, so. Using a cellphone or whatever to answer the questions is again, easy. And I didn\u0026rsquo;t have any issues with any of it. Click and go. Click your answers down if there\u0026rsquo;s anything you need to spell out, you could. There\u0026rsquo;s plenty of area for that. Not just yes or no. And if you need to spell out something you could put down whatever symptoms you were having. And that was pretty well, easy to use .\u0026rdquo; (7) ‬‬\u003c/p\u003e\u003cp\u003e\u0026ldquo;Yes, I did use it. I know I did once, and I'm not sure if the second time it took or went through\u0026hellip;And then afterwards, I just thought I\u0026rsquo;m not even doing this anymore.\u0026rdquo; (41)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrompted option for palliative care self-referral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;I thought it was okay, but I haven't had to request that yet. Well, I like that the option is out there if I needed it. So, it's just good to know that it's there and in the background and available to me if I should need it. \u0026rdquo; (24) ‬‬\u003c/p\u003e\u003cp\u003e\u0026ldquo;Yeah, I think that\u0026rsquo;s good because I think it\u0026rsquo;s a very- to me it seems like a personal choice that somebody has to make. And I do think that you never know when somebody might get to that position that they feel like they need that extra assistance. So, having the access to do that. I mean, some people might feel like they have to wait until their next appointment or till the doctor suggests it. So, I think it\u0026rsquo;s nice to kind of, I don\u0026rsquo;t know, arm your patients with the tools that they need and know that they don\u0026rsquo;t have to go through their doctor or wait on an appointment but that\u0026rsquo;s something they can reach out to when they need it.\u0026rdquo; (30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;Well, I supposed if I\u0026rsquo;d had more symptoms or something, I would have requested that, but. Like I said, I never even got so much as nauseous after my treatments and stuff. So, I really didn't think I needed much palliative care.\u0026rdquo; (7)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think that's good. Did I request one? No. Well, if I do, I would use OSU MyChart and send a message to palliative care. \u0026rdquo; (12) ‬‬\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrompted option for oncology team contact\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;I have not because at least at this point in the trial, I'm down there every single week already anyway. So, I'm discussing symptoms when I'm there. I think it's great because, like I said, sometimes going through the regular channels or trying to figure out how do I log into the portal and message my doctor. If this is somebody that's a brand-new patient, those things often can be daunting. \u0026rdquo; (19) ‬‬\u003c/p\u003e\u003cp\u003e\u0026ldquo;I think honestly, if something came up that I feel like I needed to reach out to my doctor, I would probably just call in at the office. That would be my first gut reaction. \u0026rdquo; (30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026ldquo;I call. If I don't call, well, I\u0026rsquo;ve had several times I needed information or something. And I every time I called\u0026hellip;I went straight to the source. I called the doctor's office. \u0026rdquo; (34)\u003c/p\u003e\u003cp\u003e\u0026ldquo;I have done that in MyChart. But not on the SyMPLER app.\u0026rdquo; (39)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think that was pretty emotional for both of us\u0026hellip; really the only thing kind of we knew about palliative care was more like end-of-life type care is sort of what we had in mind and so, it was a little bit, I don't know. It was a lot to watch the video, to be honest, because it was kind of like preparing for kind of a worst-case scenario is how it felt in moment.\u0026rdquo;\u003c/em\u003e (32)\u003c/p\u003e\u003cp\u003eMost participants voiced positive opinions about the weekly text reminders with some participants suggesting customization of the frequency, modality (e.g., push notifications), and day/time when reminders were sent. Participants who reported symptoms through the study app stated that the ESAS-r-CS survey was \u0026ldquo;simple\u0026rdquo;, \u0026ldquo;convenient\u0026rdquo;, and \u0026ldquo;pretty straight-forward\u0026rdquo;. Two low engagement participants cited technology concerns (\u0026ldquo;not being good at touching letters on a cell phone\u0026rdquo;) as a limitation to completing the ESAS-r-CS questionnaire via an app interface.\u003c/p\u003e\u003cp\u003eParticipants endorsed the PC self-referral as \u0026ldquo;a real good option\u0026rdquo;, although only five interviewees ( 3 high engagement; 2 low engagement) responded \u0026ldquo;yes\u0026rdquo; to this prompt. Participants cited low symptom burden (\u0026ldquo;I'm not having any symptoms whatsoever\u0026rdquo;) and insufficient knowledge of PC (\u0026ldquo;I didn\u0026rsquo;t understand what it was\u0026rdquo;) as main reasons for declining a PC referral. Participants in both cohorts reflected that PC may be beneficial for \u0026ldquo;other people\u0026rdquo; while appreciating the direct access to PC via self-referral. One high-engagement participant described how SyMPLER facilitated her PC self-referral:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, all along it was like, oh, there isn't really anything bad enough about what I'm going through to require this. But then I ended up having another surgery, and things went badly wrong and to the point where, I'm in a wheelchair now, and having a lot of pain from that. And that's when I asked for the palliative specialist\u0026hellip; I mean, it made it very easy. Honestly, if I didn't have that on the app, I'm not sure I would have made the phone call. So, that was great. \u0026rdquo;\u003c/em\u003e (25, second interview)\u003c/p\u003e\u003cp\u003eParticipants also noted acceptability of the option to request contact from their oncology team to discuss symptoms (\u0026ldquo;real helpful\u0026rdquo;) although only four participants opted for this option. Several participants voiced preference for contacting their oncology team via telephone or patient portal (e.g., MyChart) connected to the EHR.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eSuggestions for program improvement\u003c/h2\u003e\u003cp\u003eParticipants in both cohorts provided feedback on how to improve SyMPLER (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). One participant asked for a \u0026ldquo;refresher\u0026rdquo; on the education materials about PC. Participants suggested ways to make SyMPLER \u0026ldquo;more patient-centric\u0026rdquo; such as adding additional free text fields where patients could describe symptoms \u0026ldquo;in their own words\u0026rdquo;. Several participants also expressed a desire to view reports or trends of their prior ESAS responses to enable them to choose a score based on whether a symptom was better/worse than the previous day/week. To better integrate symptom reporting into their daily lives, several participants asked for further customization of the frequency (e.g., twice weekly, biweekly) and timing (e.g., day of the week, time of day) of when text reminders were delivered to their smartphone device. Some participants also suggested that a follow-up reminder could be delivered a few days after the weekly text if they forgot to report symptoms in the SyMPLER app.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSuggestions to Improve the Intervention\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCohort\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVerbatim participant quotations\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigh engagement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;I could give a section in there to where actually someone could document how they're feeling in their own words. That might be helpful.\u0026rdquo; (2)\u003c/p\u003e \u003cp\u003e\u0026ldquo;I don't think with numbers you can fully explain it. I think it needs to be more patient-centric because everybody's different and everybody reacts to it differently. The first time I went through chemo I didn\u0026rsquo;t feel anything. I really felt it this time. So, I think there's - I think it needs to be a little more in depth.\u0026rdquo; (10)\u003c/p\u003e\u003cp\u003e\u0026ldquo;It would be more beneficial if there was a way to say, have you experienced any new symptoms this week? And then like whatever you type in, then it'll ask about that specific thing in the future.\u0026rdquo; (19)\u003c/p\u003e\u003cp\u003e\u0026ldquo;Some of the symptoms it's hard to quantify and I would forget the number I gave last time\u0026hellip; So, if I can see what my last score is, it's easy for me to make a judgment, right? Am I getting better or worse? So, I can move the score up or down from last time. (31)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLow engagement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ldquo;I guess the only thing that might help is to be able to explain why this is important. I got more of a feel of we're just studying this app and seeing how it works for people and if you do it, fine, if you don't do it, fine. That's up to you but you'll still be participating as long as you sign up or say you'll do it or whatever. I guess I never got a real sense that it was really important. \u0026rdquo; (34)\u003c/p\u003e\u003cp\u003e\u0026ldquo;My recommendation would be to do a follow up reminder. Because it always seems like whatever time I got it, I was not in a position to be able to do it at that time. And then I could just completely forgot about it. For then the next Monday I got one, or it was like the time I'm starting work or something whenever the reminder comes in. And so, it was just not a good time that I could take the time to do it at that- and then I just completely forgot about it. \u0026rdquo; (39)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMost participants stated that they would recommend SyMPLER to other patients, although their reasons for recommending the program differed by cohort. While participants in the low engagement cohort stated that they would recommend SyMPLER for the purpose of advancing cancer research (\u003cem\u003e\u0026ldquo;But any help\u0026hellip; we could provide for research purposes, I think is, can only be beneficial\u0026rdquo;\u003c/em\u003e), highly engaged participants identified how the program could improve patient care:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Well, it gets them connected to the right people when they need help. And I think sometimes with the science part of it, you can slip through it, kind of slip through the cracks a little bit. \u0026rdquo;\u003c/em\u003e (2)\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eAs a DBCI, SyMPLER encourages patients to report symptoms outside the medical setting via an app-based interface and prompts them to request an oncology clinician callback and/or self-refer to PC specialist when needed for symptom management. For SMPs, DBCIs have the potential benefit of augmenting person-to-person interventions that address patient symptoms or offer PC referral only during clinic appointments. While interviews with participants support overall feasibility and acceptability of SyMPLER, key modifications to the intervention may improve patient engagement with remote symptom reporting and increase their willingness to request help for cancer-related symptoms.\u003c/p\u003e\u003cp\u003eIn healthcare, the success of a DBCI depends on the patient\u0026rsquo;s ability and willingness to repeatedly engage with the technology. In this study, patients in both cohorts noted that weekly cues, ease, and low time burden were key factors contributing to the feasibility and acceptability of SyMPLER for remote symptom reporting. Despite its simplicity, technology barriers limited some participants\u0026rsquo; abilities to report symptoms through the study app. To address this digital divide, patients may benefit from educational outreach delivered by nursing staff or lay navigators to increase their understanding and engagement with symptom monitoring outside the healthcare setting [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eReminders, delivered via SMS text to a patient\u0026rsquo;s personal cell phone, increase patient completion of health-related tasks, including cancer screenings [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e], vaccinations [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e], and medical appointments [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Participants in our study noted acceptance of this SyMPLER component and suggested the cues were helpful in reminding them to complete a potentially ignorable task (e.g., logging symptoms). In addition, participants in our study described the need for customization of the day and time when text reminders are sent in order to integrate symptom reporting with competing demands of patients\u0026rsquo; daily lives (e.g., returning to work [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]). Follow-up reminders, delivered if a task remains uncompleted, have been shown to increase completion of annual flu vaccination [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] and may be another strategy to encourage habitual symptom reporting in future iterations of SyMPLER.\u003c/p\u003e\u003cp\u003eIn the SyMPLER intervention, we chose the ESAS due to its brevity, use of a numerical visual analog scale, and validation across many languages and cancer diagnoses [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. While some SMPs have used ESAS scoring thresholds to drive PC consultation [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e], others account for intra-subject correlation (e.g., patients who tend to always report below-threshold scores despite bothersome symptoms) by offering PC when symptom scores significantly increase over time (e.g., \u0026ge;\u0026thinsp;2-point increase in an individual symptom score) [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In SyMPLER, all participants were offered PC upon each ESAS completion regardless of their reported symptom scores. Future integration of symptom-triggered prompts suggesting a PC self-referral or oncology callback when symptom scores increase or exceed predefined thresholds may inform patients about when to seek help for bothersome symptoms.\u003c/p\u003e\u003cp\u003eSelf-referral allows patients to choose whether and when to access PC for symptom management. While patients in both cohorts noted acceptance of the self-referral prompt, few could recall details about the education materials introducing PC upon study enrollment. Echoing a smaller pilot study of an SMP that prompted patients to schedule a PC appointment [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e], lack of understanding about PC may be a contributing factor to why most participants did not request a consultation through the SyMPLER study app. As healthcare providers struggle with when and why to refer patients to specialty PC [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], our study demonstrates that patients face similar uncertainty when prompted to consider a PC self-referral.\u003c/p\u003e\u003cp\u003eBy equipping an SMP with opportunities for patients to seek help, SyMPLER captures information on how a patient is feeling when they request a PC consultation. Precision PC is a framework for care delivery aimed at connecting the most symptomatic patients with specialty PC [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Unlike early PC guidelines that rely on disease-focused referral criteria [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], precision PC advocates for the use of patient-reported outcomes (PROs) to trigger an initial consultation [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] or longitudinal follow-up with an interdisciplinary PC team [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. However, there is little consensus on PRO-based referral criteria for PC. Combined with PROs, self-referral may be the most precise indicator of a patient\u0026rsquo;s need and willingness to seek help from specialty PC. In this initial iteration, SyMPLER integrates PROs with self-referral to specialty PC in a way that patients report is both feasible and acceptable after a new lung cancer diagnosis.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, we only interviewed participants exposed to the SyMPLER intervention. We may have heard more diverse perspectives about remote symptom monitoring, particularly related to technology barriers, if we had interviewed patients who declined SyMPLER enrollment due to technological concerns or lack of interest. Second, few interviewees opted for a PC self-referral, which limited our ability to ascertain why patients seek PC and whether these reasons fit within the current referral criteria recommended by consensus guidelines. Although there is a lack of racial and ethnic diversity in our study population, there is good representation across different levels of education, insurance payer source, and residential proximity to the cancer center. Females are overrepresented, which is reflected by a higher proportion of women enrolled in the SyMPLER parent study.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn this qualitative study, most participants were willing and able to remotely report cancer-related symptoms through the SyMPLER intervention. Most patients noted acceptance of the option to self-refer to PC, although few sought a PC consultation during the intervention period. Like clinicians, patients struggle with when and why to pursue a PC consultation. Patients\u0026rsquo; suggestions to improve the SyMPLER intervention may help to increase patient engagement with remote symptom reporting and PC self-referral in future studies.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding:\u003c/h2\u003e\u003cp\u003eThis work was funded through a Junior Investigator Award from The Ohio State University Department of Internal Medicine and a Young Investigator Award from the National Comprehensive Cancer Network Foundation. Salary support for Dr. Merlin is funded through a K24 award from the National Institute on Drug Abuse (K24DA056837). Salary support for Dr. Presley is funded through the K76 Paul B. Beeson Emerging Leaders Career Development Award in Aging from the National Institute on Aging (K76AG074923).\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eJ.L.A. conceptualized the project, designed the study, interpreted results, and wrote the draft manuscript. A.A.G. and A.S.M. developed the codebook for qualitative interviews. L.J.R. and A.S. cleaned interview transcripts. J.L.E. completed all participant interviews. M.M.G. supervised data collection and managed the IRB and regulatory tasks related to the project. J.S.M., J.S., and C.J.P. contributed to the study design and contributed critical review and editing of the manuscript. A.S.M. supervised qualitative analysis and study design throughout all stages, and provided critical revisions of the manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eDe-identified interview transcripts and codebooks can be shared upon written request to the corresponding author under a data-sharing agreement that provides for: i) a commitment to using the data only for research purposes and not to identify any individual participant, ii) a commitment to securing the data using appropriate computer technology; and iii) a commitment to destroying or returning the data after analyses are completed.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWebber, K., et al., \u003cem\u003eSymptom prevalence and severity in palliative cancer medicine\u003c/em\u003e. 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Bruera, \u003cem\u003eThe Edmonton Symptom Assessment System 25 Years Later: Past, Present, and Future Developments\u003c/em\u003e. J Pain Symptom Manage, 2017. 53(3): p. 630\u0026ndash;643.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZimmermann, C., et al., \u003cem\u003eSymptom screening with Targeted Early Palliative care (STEP) versus usual care for patients with advanced cancer: a mixed methods study\u003c/em\u003e. Support Care Cancer, 2023. 31(7): p. 404.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZimmermann, C., et al., \u003cem\u003ePhase II Trial of Symptom Screening With Targeted Early Palliative Care for Patients With Advanced Cancer\u003c/em\u003e. J Natl Compr Canc Netw, 2021. 20(4): p. 361\u0026ndash;370 e3.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePatel, M.I., et al., \u003cem\u003eAssociation of a Lay Health Worker Intervention With Symptom Burden, Survival, Health Care Use, and Total Costs Among Medicare Enrollees With Cancer\u003c/em\u003e. JAMA Netw Open, 2020. 3(3): p. e201023.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKaufmann, T.L., et al., \u003cem\u003eFeasibility Study of Using Electronic Patient-Reported Outcomes to Screen Patients with Advanced Solid Cancers for Palliative Care Needs\u003c/em\u003e. J Palliat Med, 2025. 28(5): p. 580\u0026ndash;591.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEnguidanos, S., et al., \u003cem\u003eHealth Care Provider Barriers to Patient Referral to Palliative Care\u003c/em\u003e. Am J Hosp Palliat Care, 2021. 38(9): p. 1112\u0026ndash;1119.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSedhom, R., L.N. Shulman, and R.B. Parikh, \u003cem\u003ePrecision Palliative Care as a Pragmatic Solution for a Care Delivery Problem\u003c/em\u003e. J Clin Oncol, 2023. 41(16): p. 2888\u0026ndash;2892.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePetrillo, L.A. and J.L. Agne, \u003cem\u003eRe-Examining Early in Early Palliative Care: Precedent, Reality, and Future Research Priorities\u003c/em\u003e. JCO Oncol Pract, 2025: p. OP2500479.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFerrell, B.R., et al., \u003cem\u003eIntegration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update\u003c/em\u003e. J Clin Oncol, 2017. 35(1): p. 96\u0026ndash;112.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTemel, J.S., et al., \u003cem\u003eStepped Palliative Care for Patients With Advanced Lung Cancer: A Randomized Clinical Trial\u003c/em\u003e. JAMA, 2024. 332(6): p. 471\u0026ndash;481.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Symptom monitoring program, Digital behavioral change intervention, Palliative care, Cancer","lastPublishedDoi":"10.21203/rs.3.rs-7420494/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7420494/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eSymptom monitoring programs (SMP) and specialty palliative care (PC) improve health-related quality of life through timely symptom management for patients with lung cancer. The primary aim of this study was to assess patients\u0026rsquo; perspectives about the feasibility and acceptability of a SMP with a prompted palliative care self-referral option.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis is a single-institution qualitative study of patients with lung cancer enrolled in a single-arm feasibility study of a mobile health application (app) that facilitates on-demand reporting of cancer-related symptoms and prompts patients to self-refer to PC for symptom management. Interview participants were purposefully sampled based on high (\u0026ge;\u0026thinsp;3 uses) vs low (0\u0026ndash;2 uses) app engagement during the first three months of study enrollment. Questions focused on feasibility and acceptability of the SMP as well as the five main components of the intervention. Individual interviews were conducted from May 2024 \u0026ndash; May 2025 by telephone, recorded, transcribed verbatim, and analyzed using thematic analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThirty-one patients were interviewed; 21 with high and 10 with low app engagement. Participants were mostly white (93.5%), female (67.7%), and \u0026ge;\u0026thinsp;60 years of age (61.3%). Most participants were willing and able to report symptoms through the study app and self-refer to PC if needed for symptom management. Participants described technology concerns and low understanding of PC as primary barriers to SMP engagement and PC self-referral, respectively.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003ePatients reported that an app-based SMP with integrated PC self-referral was both feasible and acceptable. Incorporation of participant feedback may improve engagement with future iterations of this intervention.\u003c/p\u003e","manuscriptTitle":"SyMPLER Palliative Care: a qualitative study of patient experiences with a symptom monitoring program and self-referral to specialty palliative care","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-11 17:10:10","doi":"10.21203/rs.3.rs-7420494/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7f82bfe6-2148-4733-a924-c5d8daf0d929","owner":[],"postedDate":"November 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-20T09:24:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-11 17:10:10","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7420494","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7420494","identity":"rs-7420494","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}