Monoclonal Gammopathies: Electronic Subspecialty Consultation
Authors: Burwick Nicholas , Stein Jacob , Garcia David A , Broudy Virginia C. , Richard Robert E. 
Published: April 2021

Abstract
Introduction : Non-visit electronic consultation (e-consult) is an important component of care for veterans in the VA healthcare system who require sub-specialty consultation but not urgent face to face evaluation. Since the majority of patients with monoclonal gammopathy of undetermined significance (MGUS) are low-risk of disease transformation, we reasoned that e-consult would be a safe and effective way to manage MGUS in most cases. Here we sought to characterize our current e-consult practice patterns for the surveillance of MGUS and identify key questions for future investigation.
Methods : We performed a retrospective analysis of our electronic consult database from 1/1/2010-12/31/2014 to identify cases of monoclonal gammopathy. Monoclonal gammopathy was confirmed on chart review by an attending hematologist. To be included in the analysis, a patient had to have either 1) a monoclonal protein by serum or urine protein electrophoresis (SPEP/UPEP) or immunofixation or 2) abnormal serum free light chain (FLC) ratio, using a normal reference range of 0.26-1.65, with an increase in the involved light chain. Pertinent clinical and demographic data was abstracted and was used to analyze outcomes among the cohort.
Results : We screened 3,217 electronic hematology consults to identify a cohort of 152 MGUS patients triaged for e-consult over a five-year period. E-consult services were provided for veterans from 23 different counties with an average time to completion of 3.4 days. The average size of monoclonal (M) protein was 0.25 g/dL (0-1.5 g/dL). 84% of patients had an M-protein concentration less than 0.5 g/dL. Following completion of risk-stratification studies, 113/121 (93%) of patients with available risk scores were lower risk for disease progression (0-1 risk factors). There were 11 cases with negative SPEP for whom a risk score could not be calculated. An additional 20 cases had a positive SPEP without available free light chain data. A minority of patients (29%) had FLC data available at the time of consult. At 3-months post-consult, 71% had completed FLC testing. One-third of patients had an abnormal hemoglobin (hgb) and 41% had an abnormal creatinine (cr) using the normal reference ranges. However, 96% of MGUS e-consults had a hgb &gt;10 g/dL and 90% had a cr &lt;2 mg/dL. Among those tested (n=91), one patient had skeletal abnormalities concerning for myelomatous bone disease on initial screening. One-third of cases utilized multiple e-consult encounters over time, while 15% of MGUS e-consults ultimately required a face-to-face visit with hematology. With an average follow-up of 47 months (median 44 months), there were 6 documented progression events, representing a mean rate of progression of 1% per year (Figure).
Conclusions : We find that electronic consultation is a helpful mechanism for evaluating MGUS longitudinally, decreasing travel burden, and improving timely access to care for veterans. The majority of MGUS cases triaged for e-consult at our center are low-risk by established criteria and have very low amounts of monoclonal protein. Most of these patients can be followed with routine paraprotein surveillance and deferred skeletal imaging. Timely completion of biomarker studies is critical for appropriate risk-stratification and triage. The use of additional system tools (such as task trackers) to assist with follow-up of outstanding tests may help augment services provided electronically. These observations may be generalizable to other VA centers and other health-care systems where e-consult is becoming more widely adopted.
Figure 1 Figure 1.

Disclosures
No relevant conflicts of interest to declare.