NSO-02: An Advanced Practice Provider Consult Clinic is Feasible to Evaluate Patients With Monoclonal Gammopathy of Undetermined Significance (MGUS) And Plasma Cell Disorders (PCDs)
Nurse Practitioner and Researcher Cleveland Clinic Highland Heights, Ohio, United States
Introduction: Advanced practice providers (APs) are vital in outpatient clinics in the United States, which continues to extend internationally. Access to specialized hematology/oncology (hem/onc) evaluation of monoclonal gammopathy of unknown significance (MGUS) for clinical significance is critical to patients experiencing unexplained symptoms. However, a lack of provider access can delay a correct diagnosis. With a standardized initial workup and additional training, APs are well-suited to fill this access gap. Thus, we report our experiences to improve patient access to a standardized specialty evaluation of MGUS and collaborative efforts to expedite diagnosis and treatment if necessary.
Methods: Since 2/2014, outpatient APs with at least 2 years of experience in hem/onc were deemed eligible to see new MGUS patient (pt) consults independently. A standardized procedure and diagnostic algorithms were developed with input from physicians and APs based on international guidelines for the initial workup of patients with MGUS, anemia, or suspected amyloidosis. This algorithm created a care path for all providers to follow in the organization to standardize the initial workup of MGUS. Pts were scheduled to see the AP using the central hem/onc consult schedulers, who reviewed internal and external consult requests for patients who met the criteria for MGUS. APs were required to consult with a physician if any patient had a confirmed monoclonal protein and “red flag” symptoms of hypercalcemia, renal insufficiency, anemia, polyneuropathy, suspicion of amyloidosis, POEMS, demyelinating polyneuropathy, lymphoma, or other hematologic conditions. At our center, two tumor boards were established to collaboratively discuss complex cases in 2018 (PCD) and 2021 (MGUS) and provide education.
Results: From 1/2014-3/2024, 1,466 unique pts were identified as seen by the AP for an initial consultation of MGUS based on the ICD-10 diagnosis code. All pts were referred for evaluation of MGUS either externally (ext), internally (int), or as a new patient with whom an MGUS or PCD provider had not seen within 2 years. From the initial 5 yrs from 1/1/2014-1/1/2019, 338 patients were seen by 2 APs referred ext (n=29) int (n=268) or new (n=41). For the 5 yrs from 1/2/2019-3/1/2024, 1128 patients were seen by 4 APs referred ext (n=78) int (n=904), new (n=118). An additional 28 patients were seen by a remote virtual visit. From the 398 pts seen in the initial 5-yr period, 1128 is a 183.42% increase. Additional outcomes will be reported later.
Conclusions: An AP consult clinic is feasible for evaluating patients with MGUS. A standardized workup and collaborative tumor board format allows a team approach to patient care and a forum to discuss best practices in diagnosing and managing MGUS and PCD. Expanding the initial consult model to other APs allowed an exponential increase in patient visits to manage increased patient volumes. Future analyses should focus on the role of virtual visits in this patient population.