Cold Agglutinin Disease: Virtual Patient Simulation Improves Performance in Diagnosis and Management
Authors: Rohani-Montez S Christy , Worst Michelle Arielle , Baumhover Stephanie , Mitarotondo Alyssa , Mikhael Emily , Berentsen Sigbjørn , Smith Roy 
Published: December 2024

Introduction
Timely diagnosis of cold agglutinin disease (CAD) is often difficult for healthcare providers (HCPs) due to the low prevalence, nonspecific and heterogeneous patient symptoms at presentation, and insufficient awareness amongst many clinicians. We used patient simulation, engaging hematologists in a practical learning experience to assess performance in making these choices.
Methods
This CME-certified virtual patient simulation consisted of 2 patient cases presented in a platform allowing hematologists to conduct assessments and complete open-field entries, choosing from an extensive database of diagnostic and treatment options reflecting the scope and depth of actual practice (Berentsen S, Smith RE. An Autoimmune Hemolytic Anemia Simulation: Expert Guidance on Diagnosis and Management. Available at https://www.medscape.org/viewarticle/986561). After each decision, learners received clinical guidance (CG) based on current evidence and faculty recommendations. Clinical decisions were compared pre- and post-CG using a 2-tailed paired t-test to determine P values (P&lt;.05 is significant). Rationales for clinical decisions were collected in real time. Data were collected June-December 2023.
Results
69 hematologists completed case 1 and 38 completed case 2. Statistically significant improvements in ordering appropriate diagnostic tests (P &lt;.001), referral to relevant multidisciplinary team (MDT) members (P &lt;.001), individualizing treatment selection (P &lt;.05), and educating on treatment-related adverse events (P &lt;.05) were observed post-CG across both cases.
In case 1, despite most having ordered cold agglutinin titer pre-CG, only 51% of hematologists were able to diagnose CAD without guidance. Post-CG this significantly increased to 84% (P &lt;.001). Only half of hematologists chose to refer the patient with CAD to relevant MDT members or order a follow-up appointment, but significant improvements were seen post-guidance (P &lt;.001 for both).
In case 2, pre-CG, very few hematologists selected appropriate treatments for the patient who was diagnosed with CAD, but post-CG, there were significant improvements: 26% selected sutimlimab vs 5% pre-GC (P &lt;.01); 24% selected rituximab (RTX) vs 3% pre-GC (P &lt;.01); 13% selected RTX + bendamustine vs 0% pre-GC (P &lt;.05). For those who did not choose sutimlimab or RTX, 41% and 44% respectively said this treatment was not needed at this stage. The top reason for not choosing RTX + bendamustine was the unfavorable adverse event profile (32%). The majority (87%-95%) did not select preventative vaccines both pre- and post-CG. About half of hematologists selected appropriate education options for the patients in both cases, with significant improvements of 14-17% seen post-CG.
Conclusions
These results demonstrate the success of immersive, online simulation education in improving performance in in recognizing signs and symptoms of CAD, appropriately diagnosing, assessing treatment and needed follow-up as well as adequate patient education. Areas of continued educational need include diagnostic test interpretation to be able to correctly diagnose CAD, patient education needs, treatment selection, and implementation of preventative vaccines.