Understanding Root Causes Contributing to Real-World Racial Disparities in Multiple Myeloma Care: Insights from a Mixed-Methods Study Utilizing Tethered Patient-Provider Surveys and Chart Reviews
Authors: Mikhael Joseph , Jacobson Anne , Carter Jeffrey D , Sapir Tamar 
Published: February 2021

Background
Multiple myeloma (MM) is the most common hematologic malignancy among Black patients, who experience a 2-fold increase in MM risk and earlier age of onset compared with non-Black patients. Relative to other groups, Black patients are less likely to undergo autologous stem cell transplant (ASCT), receive timely access to novel therapies (e.g., immunomodulatory drugs, proteasome inhibitors), and enroll in clinical trials (Ailawadhi Blood Adv 2019). However, when Black patients with MM do undergo ASCT or receive novel therapies, their clinical outcomes match those observed in other patient groups, with some data suggesting a possible survival advantage (Fillmore Blood 2019). Therefore, in the absence of a clear biologic rationale for different treatment patterns, it is necessary to examine structural and other barriers to optimal care. In this ongoing quality improvement (QI) initiative, we are assessing and attempting to address the root causes of disparities in care delivery among patients with relapsed/refractory (R/R) MM in 2 large oncology systems.
Methods
Building on the design of our prior QI programs (Hussein ASCO 2020), this multicomponent initiative includes patient and provider surveys (n = 70), baseline and follow-up audits of electronic medical records (EMRs) (n = 400), and small-group, team-based audit-feedback (AF) sessions.
Patient-Provider Surveys: 30 hematology/oncology healthcare providers (HCPs) and 40 patients with relapsed/refractory MM (20 African American [AA] and 20 non-AA patients, including Hispanic and non-Hispanic White patients) will complete 30-item and 35-item surveys, respectively. In addition to assessing MM treatment experiences, survey questions will evaluate health literacy, medication adherence, cancer beliefs, patient-HCP communication, and awareness of health disparities. With multiple shared questions, the surveys are designed to reveal alignments and discordances in attitudes, beliefs, perceptions, and practices regarding MM care (a) between patients and HCPs and (b) between AA and non-AA patient subgroups. In addition, HCPs' self-reported practice behaviors will be compared against documented practice patterns in the EMR audit.
EMR Audits: Variables for the baseline EMR audit include patient/disease characteristics, treatment history, clinical practice metrics, and patient-centered measures (e.g., shared decision-making) documented for 100 AA and 100 non-AA adults with R/R MM and ≥2 clinic visits within the past year. Six months after the AF sessions, the follow-up EMR audit of 100 AA and 100 non-AA patients will assess changes in EMR documentation and practice behavior.
Team-Based AF Sessions: HCP cohorts within each oncology system will participate in 1-hour live small-group AF sessions scheduled as part of each system's grand rounds series. Hematology/oncology teams will (a) assess system-specific practice gaps identified via the patient-provider surveys and baseline EMR audit, (b) prioritize areas for improvement, and (c) develop action plans for addressing root causes. Additional surveys completed before and after the AF sessions will measure changes in participants' beliefs and confidence in care delivery.
Results
Two large oncology systems in Chicago and Washington, DC, are enrolled. Preliminary HCP (n = 6) and patient (n = 9) survey data suggest discordant beliefs about patients' primary MM treatment concerns. HCPs overestimated how many patients are concerned about notfeeling confident that their treatment plan is the best for their cancer (83% vs 11%) and underestimated how many are concerned about lack of reliable transportation (0% vs 33%), difficulty communicating with their care team (0% vs 33%), meeting responsibilities at work and home (0% vs 11%), and treatment cost (0% vs 11%).
Full findings from the baseline EMR audit (n = 200) and patient and HCP surveys (n = 70), as well as outcomes from the 2 small-group AF sessions (scheduled for September 2020), will be presented.
Conclusions
Factors contributing to racial disparities in MM care are complex. QI programs are critical tools for understanding and addressing system-specific barriers to optimal care for all patients with MM.
Study Sponsor Statement
The study reported in this abstract was funded by independent educational grants from AbbVie, Inc. and Celgene Corporation, who had no role in the study design, execution, analysis, or reporting.

Disclosures
Mikhael: Amgen, Celgene, GSK, Janssen, Karyopharm, Sanofi, Takeda: Honoraria.