Improving Specialty Access for Patients with Monoclonal Gammopathy of Undetermined Significance (MGUS) and Plasma Cell Disorders (PCDs): 10 Years of Experience and a Successful Model of Care
Authors: Faiman Beth M. , Williams Louis S , Khouri Jack , Anwer Faiz , Raza Shahzad , Samaras Christy J. , Hamilton Kimberly , Scott Cynthia , Mathur Saveta , Koc Omer N. , van Heeckeren Willem J. , Valent Jason , Mazzoni Sandra 
Published: December 2024

Background: Rapid access to specialized healthcare is critical to patients, especially when diagnosed with a monoclonal gammopathy of undetermined significance (MGUS) in order to differentiate MGUS from other more serious plasma cell disorders (PCDs) such as multiple myeloma (MM), amyloidosis, Waldenstrom's macroglobulinemia (WM), high risk smoldering MM (HRSMM) and monoclonal gammopathies of clinical significance (MGCS). Historically, physicians have been the key consultant providers tasked with promptly and accurately diagnosing PCDs. Yet, physician access and patient availability can limit prompt specialty evaluation. Beginning in 2014, our PCD disease group decided that cases referred for MGUS should be scheduled with the outpatient advanced provider (AP). There are no known reports of long-term, AP-led, outpatient PCD clinics. Thus, we report our 10 years of experience improving patient access to a standardized specialty evaluation of MGUS and collaborative efforts to expedite diagnosis and treatment if necessary.

Methods: Since 2014, outpatient APs with at least two years of experience in hem/onc were deemed eligible to see new MGUS patient (pt) consults independently. Standard procedures and diagnostic algorithms were developed with input from physicians and APs based on updated international guidelines for the initial workup of patients with suspected PCDs. This algorithm created a care path for all providers at the main campus and regional sites within the organization to standardize the initial workup of MGUS. Internal (int) or external (ext) consultations were requested through a central hem/onc scheduling call center or by direct communication with a consulting provider. Patients were scheduled to see the AP for those who met the criteria for MGUS, abnormal light chains, or abnormal protein electrophoresis. Per the algorithm, APs had to consult a physician for any concern for MM, amyloidosis, WM or a MGCS. Before 2018, the AP documented the physician consultation in the medical chart. Two tumor boards (TB) were then established to collaboratively discuss complex cases and provide continuing education in 2018 (myeloma/PCD) and 2021 (MGUS).

Results: From 1/2014-3/2024, 1619 pts were identified as being seen in consultation by the AP via a secure electronic database. All pts were referred for evaluation of MGUS either ext, int, as a new patient, or as an e-consult. Ages at consult ranged from 22-94 yrs. AP consult cases were discussed between physicians and other APs at the myeloma/PCD (n=110) and MGUS (n=147) tumor boards. 65 pts were referred directly by the AP to a physician within seven days. After the AP consult, conditions diagnosed by the AP/Physician team ranged from MGUS (n=1116), MM (n=46), high-risk smoldering MM (n=42), WM/LPL/MZL/DLBCL (n=19), Amyloidosis (n=19), MGRS (n=12), MGCS (n=8), anti-MAG neuropathy (n=7) and cryoglobulinemia (n=5), among a variety of other various classical heme and other conditions. From the initial 5 yrs of the AP consult service from 2014-2019, 338 patients were seen by 2 APs referred ext (n=29) int (n=268) or new (n=41). For the five years from 2019-2024, 1128 patients were seen by 4 APs referred ext (n=78) int (n=904), new (n=118). Based on the increased volume and to further improve access, APs reviewed additional e-consults (n=153).

Conclusion: Here is the first report on a long-term AP-led MGUS consult service in large, multi-hospital system. Based on our 10 years of experience, an AP-led PCD consult service is feasible, sustainable, and reproducible in other settings. The key to success is easily accessible physician consultants, tumor board discussions, and algorithms to support decision-making. Experienced and well-trained specialty APs who follow an algorithmic approach to diagnosing PCDs are well-suited to fill the specialty access gaps in healthcare by providing patients with more flexible appointment options and a prompt and accurate diagnosis. Sharing knowledge through a multidisciplinary team approach and continuing education is critical to the model's success. Interestingly, most patients could remain with the AP to allow more time for physicians to focus on other responsibilities. Expanding the initial consult model to different APs in the last five years allowed an exponential increase in patient visits to manage increased patient volumes across the enterprise, virtual visits, and e-consult options