Improving Care for Hematologic Neoplasms During Major Disruptions

A new study has raised questions about healthcare preparedness for treating patients with hematologic neoplasms during major disruptive events, such as the COVID-19 pandemic.

Researchers found that the COVID-19 pandemic caused significant changes in visit rates among patients with hematologic neoplasms from 2020 to 2021.

A retrospective observational study, which was published in JAMA, found that documented in-person visit rates for those receiving oral therapy and outpatient infusions significantly decreased during the early pandemic months. However, the in-person visit rates returned to almost projected rates in the second half of 2020. For patients receiving inpatient infusions, no statistically significant reductions in the overall in-person visit rates among patients.

The researchers identified 24,261 patients with hematologic neoplasms who had received at least 1 systemic line of therapy between March 1, 2016, and February 28, 2021. Using a nationwide electronic health records-derived database, the researchers categorized treatments into 3 types: oral therapy, outpatient infusions, and inpatient infusions. The data were derived from 280 cancer clinics in the United States (approximately 800 sites). The median age was 68 years (IQR, 60-75 years), more than half of patients were men (58%) and non-Hispanic White (66%).

In this cohort, 6737 patients received oral therapy, 15,314 received outpatient infusions, and 8316 received inpatient infusions. The researchers used time-series forecasting methods to compare actual versus the forecasted visit rates. The study showed that during the early pandemic months (March to May 2020) there was a 21% reduction in in-person visit rates averaged across oral therapy and outpatient infusions.

The study also showed that reductions in in-person visit rates were significant for all treatment types for multiple myeloma (MM; oral therapy: 29% reduction; outpatient infusions; 11% reduction; inpatient infusions: 55% reduction).

“This is a very large population of real-world patients in hematology, especially as hematologic malignancies are not very common. Analyzing real-world data sets with larger cohorts of patients can accelerate our understanding of disease management and outcomes in unmet need populations, like those with hematologic malignancies,” said corresponding author Gauran Gopal, MD, who is with the Division of Hematology-Oncology at the University of Alabama at Birmingham.

Telemedicine visit rates were highest for patients receiving oral therapy, with greater use in the early pandemic months and a subsequent decrease in later months. The study authors noted that the pandemic greatly impacted cancer care due to the increased risk of morbidity and mortality among individuals with cancer and COVID-19. This forced healthcare facilities to create empirical guidelines focused on balancing risks of treatment delays against viral illness.

When stratified by disease, patients with MM had significant reductions within each treatment type. Between March and May 2020, the observed in-person visit rate for patients receiving oral therapy was 29% lower than the forecasted visit rate. Between April and May 2020, the observed in-person visit rate for patients receiving outpatient infusions was 11% lower than the forecasted visit rate during the same time period. Similarly, the observed in-person visit rate for patients receiving inpatient infusions was 55% lower than the forecasted visit rate in April and May 2020.

The authors reported there were significant reductions for patients with chronic lymphocytic leukemia who were receiving oral therapies (28% reduction, April to May 2020) and outpatient infusion therapies (20% reduction, April 2020). Patients with mantle cell lymphoma receiving outpatient infusion therapies had a 38% reduction in in-person visit rates in April 2020.

The authors noted that real-world evidence generated from data collected during the pandemic can help identify what interventions worked and what needs to be optimized should another pandemic occur. They said this is particularly important for patients with malignant hematologic diseases, who have very efficacious therapies but are prone to infectious complications.

During the pandemic period of March 2020 through February 2021, the mean (SD) telemedicine visit rates were greatest for patients who received oral therapy (0.07 [0.03] visits per patient per month), followed by inpatient infusions (0.07 [0.03] visits per patient per month) and then outpatient infusions (0.05 [0.01] visits per patient per month) over all diseases combined. Only patients with MM had a significant reduction in in-person visits for inpatient infusions during the early pandemic period.

Lindsay Wilde, MD, an associate professor at Thomas Jefferson University and researcher at the Sidney Kimmel Cancer Center, Philadelphia, Pennsylvania, said it is critical to quantify the impact that the COVID-19 pandemic had on the delivery of care for patients with hematologic malignancies and how patient outcomes were affected. “We can use the information gained from studies such as this one to improve our current care model, particularly through optimization of telemedicine utilization, and to ensure that we are well prepared to handle any future unexpected disruptions to patient care,” she said.

Telemedicine use is still growing in popularity due to patient demand and is likely to increase over time, especially as younger generations who are most comfortable with telehealth technology begin to age. “Although telemedicine visits may not be appropriate for all individuals with hematologic neoplasms, they can be a valuable tool for improving quality of life and maintaining quality of care for appropriate patients,” said Dr Wilde.

Sagar Patel, MD, an assistant professor in the Transplant and Cellular Therapy Program at the Huntsman Cancer Institute at the University of Utah, Salt Lake City, Utah, said the current study enhances the understanding of practice patterns in the hematology community. “The COVID pandemic dramatically changed our care delivery models, with a shift to telemedicine. I think some of the adoption of telemedicine was due to easing of medical state licensure rules, which allowed care of patients across state borders. The hematology community can learn how to deliver care using technology, which will aid access to care for patients in underserved communities,” said Dr Patel.

As telemedicine continues to play a larger role in hematology, Dr Patel noted it will require greater participation from licensing agencies to allow cross-border visits. In addition, digital tools to track symptoms or address patient questions beyond the visit will also be part of the next generation of care. “However, there will be limits to telemedicine visits, like those undergoing a bone marrow transplant, who can develop physical signs suggestive of a complication, such as graft-versus-host disease,” said Dr Patel.

Reference

Goyal G, Lau KW, Wang X, et al. The COVID-19 Pandemic and in-person visit rate disruptions among patients with hematologic neoplasms in the US in 2020 to 2021. JAMA. Published online June 5, 2023. doi:10.1001/jamanetworkopen.2023.16642