Home › Multiple Chronic Conditions › NCT05282654

Real-time Symptom Monitoring Using ePROs to Prevent Adverse Events During Care Transitions

Who can join

Ages 18 and older · All sexes

Inclusion Criteria:

* Adult (18 years or older)
* Hospitalized on the general medicine services at Brigham and Women's Hospital or Brigham and Women's Faulkner Hospital for at least 24 hours
* Have a discharge status of home, home with services, or facility
* English-speaking patients or their English-speaking legally designated healthcare proxy or next of kin (i.e., a family caregiver)
* Non-English-speaking patients who have an English-speaking legally designated healthcare proxy or next of kin (i.e., a family caregiver)
* Two or more chronic conditions: Anxiety, Asthma\*, Arthritis (Osteoarthritis, Rheumatoid), Atrial Fibrillation, Cancer\*, Cerebral vascular accident, Chronic kidney disease\*, Chronic obstructive pulmonary disease (COPD)\*, Cirrhosis, Coronary artery disease/Ischemic heart disease, Dementia, Depression, Diabetes mellitus\*, End-stage renal disease\*, Heart failure\*, Hepatitis B, C\*, HIV/AIDs, Hyperlipidemia, Hypertension, Inflammatory bowel disease, Osteoporosis, Sickle cell disease, Substance abuse (Alcohol/Opioid)

Exclusion Criteria:

* Less than 18 years of age
* Less than two chronic conditions
* Hospitalized less than 24 hours
* No identifiable healthcare proxy or next of kin (i.e., a family caregiver)

About the study

This study aims to predict and minimize post-discharge adverse events (AEs) during care transitions through early identification and escalation of patient-reported symptoms to inpatient and ambulatory clinicians by way of predictive algorithms and clinically integrated digital health apps. We will (1) develop and prospectively validate a predictive model of post-discharge AEs for patients with multiple chronic conditions (MCC); (2) combine, adapt, extend, and iteratively refine our EHR-integrated digital health infrastructure in a series of design sessions with patient and clinician participants; (3) conduct a RCT to evaluate the impact of ePRO monitoring on post-discharge AEs for MCC patients discharged from the general medicine service across Brigham Health; and (4) use mixed methods to evaluate barriers and facilitators of implementation and use as we develop a plan for sustainability, scale, and dissemination.

What is being tested

• ePRO Application (behavioral)

Sponsor: Brigham and Women's Hospital · Participants: 1,300 · Started: Feb 1, 2022

Contact the study team

• Anuj Dalal, MD · Phone: (617) 525-8891
• Savanna Plombon, MPH · Phone: 857-307-2668

Official record on ClinicalTrials.gov — NCT05282654

Locations in the U.S.

Conditions

• Multiple Chronic Conditions

From ClinicalTrials.gov, data retrieved Sep 30, 2026. Each study sets its own eligibility; the study team decides who can join.