Health care utilization patterns and follow-up care of elderly patients with monoclonal gammopathy
Creators: name: Wu, Joanne
Publisher: name: The University of North Carolina at Chapel Hill University Libraries
Year: 2003

description: Purpose: To assess adherence to existing clinical practice standards regarding screening and monitoring of patients with monoclonal gammopathy of undetermined significance (MGUS) to detect progression to multiple myeloma. To accomplish this, this study will determine if having MGUS or a higher level of monoclonal protein (M-protein) significantly increases measures of health care utilization. Background: Current clinical standards recommend monitoring MGUS patients with annual serum protein electrophoresis (SPEP) to detect changes in M-protein level. It is important to assess whether MGUS patients seek sufficient care and are adequately followed, because a significant portion of MGUS cases can progress to more clinically significant plasma cell disorders such as multiple myeloma. Patients and Methods: Subjects were from the Duke Established Populations for the Epidemiologic Study of the Elderly, a random sampling of community residents. Subjects were interviewed annually from 1986-1992 and once in 1996 to assess a broad range of social and health conditions, including health utilization patterns. Subjects aged 70 or older (n=1730), consented to a blood draw in 1992. SPEP and immunofixation were used to determine monoclonal immunoglobulins, and 106 subjects were diagnosed with MGUS. In 1996, subjects were asked about their health care utilization practices, including number of hospitalizations, outpatient medical visits, emergency room (ER) visits, and nursing home (NH) admissions in the past year. Student's t-test analysis for continuous variables and Fisher exact test for categorical variables were used to compare MGUS and non-MGUS subjects on several factors. Pearson's correlation between M-protein level and health care utilization outcomes was performed. Linear regression models were used to determine the independent effect of the presence of MGUS on health care utilization when controlled for demographics, habits, and comorbidities. To validate the MGUS subjects' responses and assess the completeness of follow-up care, a medical record chart review study was performed. Results: The number of ER visits was significantly lower (p=0.04) and the number of NH admissions significantly higher (p=0.04) in subjects with MGUS compared to those without. The number of hospitalizations and outpatient visits were not significantly different between MGUS subjects and controls. M-protein level was found to be correlated with the number of ER visits (r=0.48, p<0.0001) and hospitalizations (r=0.60, p=0.02), but not with the number of outpatient visits or NH admissions. Qualitative assessment of medical charts revealed sparse and incomplete medical follow-up of MGUS. Conclusion: It would be expected that, if adequately followed, MGUS patients should experience higher health care utilization compared to those without. We found that patients with MGUS had increased NH admissions and decreased ER visits but did not differ significantly in number of hospitalizations or outpatient visits, a better indicator of follow-up care for MGUS. M-protein level was associated with the number of ER visits and hospitalizations, but not NH admissions or outpatient visits. Combined with the inadequate follow-up seen in the medical records, these findings suggest a need to increase awareness among patients and physicians of existing guidelines for follow-up care of an MGUS patient and the significant potential for MGUS to develop into more clinically significant disease or malignancy.