Although survival of patients with multiple myeloma (MM) has improved in the last decade, achieving optimal outcomes requires timely delivery of anti-myeloma therapy as well as adherence to supportive care guidelines and patient education. We hypothesized that a multidisciplinary approach of a collaborative physician-pharmacist MM clinic would have a positive impact on clinical measures such as guideline adherence as well as improve the workflow process and prevent treatment delays.
From March 2014 to February 2015, we initiated a collaborative MM clinic at our institution, whereby in addition to normal physician care, a dedicated board-certified oncology pharmacist provided consultation on all new and continuing patients. The pharmacist provided education and medication lists, completed medication reconciliation, monitored for adherence and side effects, recommended management of toxicity and supportive care, and navigated issues involving enrollment and access to oral specialty medications. All consultations were documented in the patient's medical chart using a template addressing these key components. Outcomes were compared to those of patients being treated by the same physician during the previous year, when ad-hoc pharmacist consultation was available (traditional model). We compared clinical measures related to guideline adherence and analyzed delays in obtaining immunomodulator drugs (IMiDs) using available dispensing records.
Patient characteristics were similar between the collaborative and traditional models including age, sex, race, ISS stage, protein subtype, treatment type, and prior number of therapies. During the 12-month study period when a collaborative model was implemented, 399 pharmacist consultations occurred during 551 physician visits (n=57 patients). During the prior year when a traditional model existed, there were 26 pharmacist consultations on 355 physician encounters (n=44 patients) (7.3% versus 72.4%, p<0.0001).
We observed improved adherence to bisphosphonates (BP) in the collaborative clinic (55 (96%) versus 30 (68%) patients, p=0.0002). Among patients receiving BP, the time to initiation from diagnosis and re-initiation after autologous stem cell transplant (ASCT) was 5.5 versus 97.5 days (p<0.001) and 12.5 versus 135 days (p<0.001) among the collaborative and traditional clinic, respectively. One hundred percent of patients in the collaborative clinic versus 41% of patients in the traditional clinic received concomitant calcium and vitamin D (p<0.001). In patients receiving IMID-based regimens, appropriate VTE prophylaxis was prescribed in 52 (100%) versus 29 (76%) patients in the collaborative and traditional clinic, respectively (p<0.0002). Appropriate use of acyclovir prophylaxis in patients receiving proteasome inhibitor-based treatment was observed more frequently in the collaborative clinic (98% versus 56%, p=0.004). Although the number of patients receiving Pneumocystis Jirovecii pneumonia prophylaxis post-ASCT was similar (93 versus 100 percent, p=0.4), the time to initiation of prophylaxis was shorter in the collaborative clinic (11 versus 40.5 days, p<0.0001). Finally, influenza vaccination administration was higher in the collaborative clinic (76 versus 24 percent, p<0.001). When analyzing delays in obtaining IMiD therapy, we found that the median time from when the treatment plan was noted in the medical chart to when the IMiD was first filled was 7 (range: 0-32) vs. 15 (range: 3-62) days in the collaborative and traditional clinic, respectively (p=0.002). Finally, there was a significant reduction in treatment delays observed in the collaborative compared to the traditional clinic (21% vs. 85% of patients undergoing a delay, p<0.0001).
Here we pilot a multidisciplinary approach that leads to increased guideline adherence and prevents delay in anti-myeloma treatment. The collaborative clinic model could be applied to several different practice sites in order to establish an improved and more systematic approach in the management of MM patients. Prospective studies analyzing clinical outcomes, patient satisfaction and cost effectiveness of this approach are warranted.
Wirth: Celgene: Consultancy, Honoraria. Patel: Celgene: Consultancy, Honoraria.
Asterisk with author names denotes non-ASH members.