Key Findings from a Transformative Quality Improvement Initiative on Advancing CAR T-Cell Treatment in Non-Hodgkin Lymphoma
Authors: Kamdar Manali K. , Moses-Okwei Ellie , Sullivan Shelby , Carter Jeffrey , Heggen Cherilyn 
Published: December 2023

Background
Chimeric antigen receptor (CAR) T-cell therapy can transform outcomes for eligible patients with relapsed/refractory non-Hodgkin lymphoma (NHL). However, community-based care teams face challenges, including identifying eligible patients and coordinating referral and care, hindering integration into clinical practice. PRIME conducted a quality improvement (QI) initiative to better understand the challenges community oncology teams encounter in coordinating CAR T-cell therapy for patients with NHL and to bridge the gap between tertiary referral centers and large CAR T-cell centers.
Methods
This QI initiative included baseline provider surveys (n = 60), pre- and post-surveys of providers (n = 55) participating in team-based audit-feedback (AF) sessions (Table 1) and 90-day follow-up surveys. Survey questions were designed to evaluate practice patterns, challenges, and barriers to providing CAR T cell therapy to NHL patients. Care teams from each clinic, along with a CAR T-cell expert from the regional academic center and nationally renowned expert NHL CAR T-cell physician, participated in AF sessions to (a) assess system-specific practice gaps identified via the provider surveys, (b) prioritize areas for improvement, and (c) develop action plans for addressing root causes.
Results
Provider Surveys: Providers' top reported challenges managing patients with NHL were individualizing treatment plans (33%), patient nonadherence/lack of follow-up (23%), and patient health literacy (20%). Specific barriers to using CAR T-cell therapy included identifying patients eligible for treatment (45%), gaining approval from the insurance company (40%), and transferring the patient to a CAR T-cell center for infusion (27%). When asked about clinical practices, 48% of providers reported discussing novel therapies for NHL in detail with their patients, and 51% of providers often or always refer eligible patients for CAR T-cell therapy. While 45% of providers rated the level of collaboration/communication between CAR T-cell centers and oncology clinics as very good/excellent, more than half felt it could be better, citing insufficient sharing of patient information (38%), and lack of expertise in CAR T-cell administration among clinic staff (18%) as common challenges.
Small Group AF Sessions: HCPs participating in the A/F sessions reported key challenges of treatment with CAR T-cell therapy as gaining approval from insurance companies (33%), managing patients post-treatment (26%), and identifying patients eligible for treatment (22%) (Figure 1).Improvement in very high/high confidence were noted in identifying eligible patients for CAR T-cell therapy (51% to 84%) and managing adverse/late effects of CAR T-cell therapy in patients with NHL (46% to 85%). Action plans outlined to achieve CAR T-Cell therapy goals included: increase efforts to facilitate timely patient referrals for CAR T-cell therapy, improve communication between referral centers and CAR T-cell therapy performing centers, and enhance patient knowledge and expand supportive care discussions for CAR T-cell therapy.
Follow-up Surveys: In 90-day follow up surveys (n = 12), 92% of respondents reported good/very good/excellent communication and collaboration between CAR T-cell centers and oncology clinics. Additionally, 75% report improved identification of eligible patients for CAR T-cell therapy. Despite these improvements, clinics top challenge of gaining approval from the insurance company for CAR T-cell therapy (33%) persists.
Conclusions
Through this QI initiative, clinical teams created and implemented action plans to close gaps in identifying eligible patients, coordinating CAR T-cell therapy referral and approval, and providing counseling and obtaining consent among hematology/oncology team members. Following the initiative, meaningful confidence gains were noted in identifying eligible patients for CAR T-cell therapy and managing adverse/late effects of treatment. Action plans developed by HCPs following this QI initiative, will be addressed in future initiatives to support evidence-based integration of CAR T-cell therapies into NHL care to optimize patient outcomes.
Study Sponsor Statement
The study reported in this abstract was funded by an independent educational grant from Bristol Myers Squibb, who had no role in the study design, execution, analysis, or reporting.