Emily S. Van Laar, MS1 and Neha S. Korde, MD2[1]Medscape, LLC, New York, NY, USA; [2]Memorial Sloan Kettering Cancer Center, New York, NY, USA

Successful Assessment and Educational Intervention of Guideline-based Approaches for the Management of Multiple Myeloma

background

Although the availability of more-effective treatment strategies for multiple myeloma has led to a reduction in the mortality rate over the past decade, responses to treatment are often transient and the disease remains incurable.[1] The 5-year survival rate for patients with myeloma is now estimated to be higher than 70% for transplant-eligible patients and approximately 50% for elderly transplant-ineligible patients.[1] Although recent advances in the care of patients with multiple myeloma have been impressive, about 10% to 15% of patients have a poor prognosis and urgently require improved therapies.[2] The management of myeloma has evolved rapidly, resulting in the need to integrate guideline-adherent management approaches to improve the quality of care for patients with multiple myeloma. A study was conducted to determine if a case-based online CME intervention on the selection of treatment for multiple myeloma could improve the knowledge and clinical decision making of hematologists/oncologists.

methods

A cohort of practicing hematologists/oncologists participated in an innovative text-based CME activity that used problem-based learning via case-based instruction to model challenges in practice (Figure 1).[3] Each of the 2 patient cases included 4 clinical decision questions and 4 knowledge assessment questions (Figure 1).

• Clinical decision questions provided tailored feedback and clinical consequences based on the specific answer choice selected and allowed learners who answer the question incorrectly on the first attempt an opportunity to answer it again (a second attempt) after feedback was provided.

• For the clinical decision questions, an overall effect size was calculated using Cohen’s d formula to show the magnitude and strength of the consequence-based feedback learning method, along with a percent improvement that measured the percentage of successes with the consequence-based feedback method in place (eg, percentage of learners who answered questions correctly on second attempt after feedback). Effect sizes greater than 0.8 are considered large, between 0.8 are 0.4 are medium, and less than 0.4 are small.

• Knowledge assessment questions were placed before exposure to educational content (pre-assessment questions) and repeated after exposure to the educational content (post-assessment questions).

• A paired 2-tailed t-test was used to assess differences in mean scores between knowledge assessment questions pre- and post-education. Pearson’s χ2 statistic was used to measure changes in responses to individual questions. P-values of less than .05 indicated statistical significance.

• The CME activity launched on January 16, 2015, and data were collected for 30 days.

conclusions referencesThis study demonstrated the success of a case- and consequence-based educational intervention on improving clinical decisions of hematologists/oncologists in the assessment and management of multiple myeloma. Follow-up education on current and emerging guideline recommendations is required to improve clinical decision making.

1. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Multiple myeloma. V.4.2015. 2015. http://www.nccn.org. Accessed August 19, 2015.

2. Ocio EM, Richardson PG, Rajkumar SV, et al. New drugs and novel mechanisms of action in multiple myeloma 2013: a report from the International Myeloma Working Group (IMWG). Leukemia. 2014;28:525-542.

3. Korde, NS. Differentiating Therapeutic Approaches for Patients With Multiple Myeloma. Medscape Education Oncology. January 16, 2015 http://www.medscape.org/viewarticle/832077. Accessed August 19, 2015.

acknowledgmentsThe educational activity and outcomes measurement were funded through independent educational grants from AbbVie, Celgene Corporation, Novartis Oncology, Onyx Pharmaceuticals, Inc., and Takeda Oncology CME.

For more information, contact Emily Van Laar, Director, Educational Strategy, Medscape, LLC, evanlaar@medscape.net.

resultsTable 1 summarizes the effects of the educational intervention on specific learning concepts.

• For clinical decision questions of hematologists/oncologists (N=213), 31% and 83% of learners made correct clinical decisions on the first attempt and between 11% and 48% of additional learners answered the questions correctly on the second attempt, with an overall large educational effect size of d=1.601 (Figure 2). Topics in which practice improvement occurred included:

» Impact of performance and/or functional status on patient’s eligibility for higy-dose therapy (HDT )and autologous stem cell transplant (ASCT)

» Selecting therapy based on prognostic factors or patient’s eligibility for HDT/ASCT » Use of maintenance approaches » Accurate risk stratification » Managing peripheral neuropathy

• For knowledge assessment questions, statistically significant improvements (n=213; P<.05) were detected for up to 193% improvement on post-assessment concepts, which indicated a large educational effect size of d=1.408 (Figure 3). Topics for which significant improvements were observed included:

» International Myeloma Working Group (IMWG) recommendation of stem cell harvesting timing after induction therapy

» IMWG-recommended lenalidomide dose in a patient with multiple myeloma and chronic heart failure whose creatinine clearance is <30 mL/min

» Identifying that acyclovir or valacyclovir is unnecessary in an elderly patient with multiple myeloma who is on continuous lenalidomide and low-dose dexamethasone therapy

Patient Cases

Patient #1Linda is a 68-year-old woman who presents with pathologic left humeral fracture. She notes mild fatigue and pain that she says is well-controlled with nonsteroidal anti-inflammatory drugs. Her medical history includes hypertension that is well controlled with nifedipine. She is retired but maintains an active life-style (walking/hiking 1 to 2 miles 3 times weekly and attends zumba classes regularly).

Patient #2Paul is a 79-year-old man who presents with fatigue. His blood sample is sent for laboratory analysis. Workup shows M-protein of 3.2 g/dL, IgA κ on SPEP, and BM biopsy shows 30% κ-restricted plasma cells. Skeletal survey is normal.Paul has a medical history of diabetes, coronary artery disease with stents placed 10 years ago, and hypertension. He lives alone, maintains primarily a sedentary lifestyle, but neighbors visit often to check in on him. He does not complain of peripheral neuropathy or pain.

ONLINE CASE-BASED CME FORMAT WITH BRANCHING TECHNOLOGY AND CLINICAL DECISION POINTSfigure 1

FIRST ATTEMPT

EDUCATION

SECOND ATTEMPT

EFFECT OF EDUCATION

Correct

Educational Reinforcement

Reinforced Clinical Competence

Improved Clinical Competence

Unaffected Clinical Competence

Educational Intervention

Incorrect

IncorrectCorrect

table 1 MULTIPLE MYELOMA LEARNING GAPS AND EFFECT OF CME ON PHYSICIAN PERFORMANCE

Learning Objectives Corresponding Questions

Selected Clinical Decisions

Selected Knowledge Assessment

Select and apply appropriate tools for assessing a patient’s eligibility for HDT/ASCT in the setting of MM

Clinical Decision Questions: 1, 6

Knowledge Assessment Question: 7

22% of hematologists/oncologists improved clinical decisions related to determining eligibility for HDT and ASCT.

62% of hematologists/oncologists improved in their ability to utilze IMWG recommendations for dose adjustments of lenalidomide in a patient with chronic renal impariment.

Implement a tailored treatment strategy for achieving remission in patients with MM based on their eligibility for transplantation

Clinical Decision Questions: 3, 5, 8

Knowledge Assessment Questions: 2, 4, 7

17% of hematologists/oncologists improved clinical decisions related to treatment selection in patients with high-risk features.

48% of hematologists/oncologists improved clinical decision of maintenance treatment after a patient has an ASCT and achieves very good partial response.

48% of hematologists/oncologists improved clinical decision of the appropriate treatment selection of continuous Rd.

3% of hematologists/oncologists improved their knowledge about the underlying risk factors that contribute to poor clinical outcomes in patients with MM.

23% of hematologists/oncologists improved their knowledge on IMWG recommendation of timing of stem cell collection after induction therapy.

Develop a plan for preventing and managing therapy adverse effects in patients with MM

Clinical Decision Questions: 10

Knowledge Assessment Questions: 7, 9

11% of hematologists/oncologists improved clinical decision of managing peripheral neuropathy in a patient receving subcutaneous bortezomib.

57% of hematologist/oncologists improved their knowledge that acyclovir or valacyclovir is unnecessary in an elderly patient with MM who is on continuous Rd therapy

ASCT = autologous stem cell transplant; HDT = high-dose therapy; MM = multiple myeloma; Rd = lenalidomide plus dexamethasone.

CLINICAL DECISION QUESTIONS: PERCENTAGE OF HEMATOLOGISTS/ONCOLOGISTS (N=213) WITH CORRECT RESPONSES (ON FIRST ATTEMPT AND SECOND ATTEMPT) BY QUESTION

PERCENTAGE OF HEMATOLOGISTS/ONCOLOGISTS (N=213) WITH CORRECT RESPONSE BY QUESTION (PRE- AND POST-CME QUESTIONS)figure 2 figure 3

Question #1 Which factor(s) should you consider to determine Linda’s eligibility for high-dose therapy (HDT) and autologous stem cell transplantation (ASCT)? (Performance status and/or functional status)

Question #3 Because Linda’s MM is International Staging System (ISS) III and harbors t(4;14), what kind of induction therapy would you recommend to her? (Bortezomib-based induction therapy)

Question #5 Linda receives lenalidomide, bortezomib, and low-dose dexamethasone (RVd) induction therapy, proceeds with an upfront HDT/ASCT and achieves very good partial response. What would you recommend next to Linda? (RVd consolidation and maintenance with lenalidomide- or bortezomib-based therapy)

Question #6 Paul has fluorescence in situ hybridization (FISH)/cytogenetic abnormality include hyperdiploid and t(11:14) translocation. Based on the FISH/cytogenetic analysis, which risk category would you place Paul’s multiple myeloma? (Standard)

Question #8 What is 1 of the treatment options you would recommend to Paul that he is most likely to benefit from? (Continuous Rd)

Question #10 After 2 cycles of cyclophosphamide, bortezomib, and dexamethasone (CyBorD), however, Paul starts experiencing peripheral neuropathy. What should you do next to improve Paul’s condition? (Reduce bortezomib dose to 1.0 mg/m2 and/or switch to once-weekly subcutaneous administration)

Question #2 What demonstrated risk factor portends worse clinical outcome with currently available therapies including HDT/ASCT? (Adverse cytogenetics such as t(4,14) and/or del[17p])

Question #4 After how many cycles of induction therapy should stem cells be harvested? (3 to 4)

Question #7 What lenalidomide dose should be used in a patient with MM and coronary heart failure whose creatinine clearance is <30 mL/min? (15 mg every other day)

Question #9 Which of the following would you consider unnecessary in an elderly patient with MM who is on continuous Rd therapy? (acyclovir or valacyclovir)

QUESTION #1 QUESTION #3 QUESTION #5 QUESTION #6 QUESTION #8 QUESTION #10

1st Attempt Correct

0%

25%

50%

75%

100%

2nd Attempt Correct Hematologists/Oncologists (n=213)

22%

74%

17%

78%

24%

70%

14%

75%

11%

83%48%

31%

Percentage of Participants With Correct Responses (on 1st Attempt and 2nd Attempt) by Question

QUESTION #9QUESTION #7QUESTION #4QUESTION #2

% Correct Pre

P=.103 P<.05 P<.05 P<.05

0%

25%

50%

75%

100%

% Correct Post Relative Percentage Change

Percentage of Participants With Correct Response by Question (Pre- and Post-assessment Questions)

95% 98%

75%

98%

31%

92%

38%

93%

3% 31% 193% 141%