Abstract
Introduction: High-dose melphalan followed by autologous stem cell transplantation (HDM/ASCT) remains a cornerstone of multiple myeloma (MM) therapy. While safe and effective, HDM/ASCT involves a substantial increase in short-term healthcare utilization. Studies of healthcare utilization often omit modern forms of remote healthcare utilization, including electronic messages sent to physicians' offices. We sought to evaluate the frequency of these remote unscheduled healthcare interactions (rUHIs) and identify factors predictive of remote healthcare utilization in this MM patient population.
Methods: We retrospectively analyzed data from MM patients undergoing HDM/ASCT at a high-volume transplant center. To reduce the risk of confounding bias, data were restricted to only patients treated after 04/01/2022, when the frequency of new COVID-19 infections saw minimal acute increases, until the data cutoff of 07/02/2024. To ensure consistency in care, only patients from a single physician were selected for analysis. Patient demographics and disease characteristics were collected, along with incidence and cause of rUHIs identified by manual chart review by investigators with nursing experience. rUHIs were defined as any form of unscheduled contact between patients and the physician's office that did not involve an in-person visit or scheduled telehealth appointment. This included messages sent to the physician via online patient portals as well as telephone calls to the physician's office. Data were collected for 90 days from the time of cell infusion. Statistical analyses were performed using individual, 2-sided, unpaired t-tests as well as linear regression analysis and confirmed with multivariate analysis.
Results: We identified 100 patients undergoing HDM/ASCT during the observation period. Among these the median age was 63, 57% were men, 88% received HDM/ASCT as part of their first line of treatment, 28% underwent ASCT in the outpatient setting (with 9 of these patients ultimately requiring inpatient admission), 75% of patients received their prior MM-directed care at the same center as their ASCT. A median of 4 rUHIs were identified among the population (0 – 20), with the majority due to patient education (19%), care logistics (17%), symptoms of infection (12%), dermatologic symptoms (9%), or GI symptoms (7%). Less than 9% of rUHIs led to escalation of care to in-person assessment. Several characteristics predicted rUHIs. Patients with pre-admission ECOG scores of 1 had a 2.1-fold increase in rUHIs compared to those with ECOG scores of 0 (P = 0.0001). High HCT-CI scores were associated with increased rUHIs, with each additional HCT-CI point associating with a 9.9% increase in rUHIs (P = 0.016). Compared to patients referred for HDM/ASCT by in-center MM specialists, individuals referred for HDM/ASCT from outside the transplant center oncologist had a 1.8-fold increase in rUHI incidence (P = 0.006). Finally, despite having fewer total days as outpatients during the 90-day follow-up period, patients who received HDM/ASCT as inpatients had a 2.1-fold increased number of rUHIs compared to those who received HDM/ASCT as outpatients (P = 5x10-5). When incorporating these four features into multivariate analysis, only HCT-CI score was no longer significantly associated with rUHI incidence. Several variables were not associated with increased rUHIs, including patient gender, age, ISS/RISS stage, cytogenetic risk, melphalan dose, incidence of engraftment syndrome, or number of stem cells infused.
Conclusion: Modern technology has allowed for increased remote contact between patients and their physicians' offices. The most common reasons for remote contact were to address education gaps and to review care logistics. In our cohort, rUHIs rarely lead to escalation of care to an unplanned in-person visit, supporting their use for addressing low acuity issues. Markers of patient fitness, including low ECOG scores, low HCT-CI scores, and outpatient HDM/ASCT candidacy, were all associated with lower rUHI utilization. Patients who received induction therapy at an outside institution had increased rUHI utilization. An increased awareness of the factors associated with high rUHI usage may identify patients who require additional counseling throughout their HDM/ASCT treatment course.
