Interventions to Increase Leukocyte Testing during Treatment with Dimethyl Fumarate
Paul A Heidenreich1,2, Shoutzu Lin1, Parisa Gholami1
1Veterans Affairs Palo Alto Health Care System, Palo Alto, CA 94304, USA.
Abstract:
Dimethyl fumarate (DMF), a treatment for multiple sclerosis, may cause leukopenia and infection. Accordingly, periodic white blood cell (WBC) monitoring is recommended. We sought to evaluate the US Department of Veteran Affairs' safety program which provides facilities with a list of patients prescribed DMF therapy without a documented white blood cell count (WBC). We identified 118 sites with patients treated with DMF from 1 January 2016 through 30 September 2016. Each site was asked if any of seven interventions were used to improve WBC monitoring (academic detailing, provider education without academic detailing, electronic clinical reminders, request for provider action plan, draft orders for WBC monitoring, patient mailings, and patient calls). The survey response rate was 78%. For the 92 responding sites (78%) included sites (1115 patients) the mean rate of WBC monitoring was 54%. In multivariate analysis, academic detailing increased the rate by 17% (95% CI 4 to 30%, p = 0.011) and provider education increased the rate by 9% (95% CI 0.6 to 18%, p = 0.037). The WBC monitoring rate increased by 3.8% for each additional intervention used (95% CI 1.2-6.4%, p = 0.005). Interventions focused on the physician, including academic detailing, were associated with improved WBC monitoring for patients at risk for leukopenia from DMF treatment.
Insights
Dimethyl fumarate (DMF) treatment for multiple sclerosis requires white blood cell (WBC) monitoring. Physician-focused interventions, like academic detailing, significantly improved monitoring rates for patients at risk of leukopenia.
Area of Science:
- Pharmacovigilance
- Clinical Quality Improvement
- Multiple Sclerosis Therapeutics
Background:
- Dimethyl fumarate (DMF) is a multiple sclerosis (MS) treatment associated with potential leukopenia and infection risks.
- Periodic white blood cell (WBC) monitoring is crucial for patients on DMF therapy.
- The US Department of Veteran Affairs (VA) implemented a safety program to identify patients on DMF lacking documented WBC counts.
Purpose of the Study:
- To evaluate the effectiveness of interventions aimed at improving WBC monitoring in patients prescribed DMF within the VA system.
- To identify specific interventions associated with higher WBC monitoring rates.
- To assess the impact of multiple interventions on monitoring adherence.
Main Methods:
- A survey was distributed to 118 VA sites treating patients with DMF between January 1, 2016, and September 30, 2016.
- Sites were queried on the use of seven specific interventions to enhance WBC monitoring.
- A multivariate analysis was conducted on data from 92 responding sites (78% response rate) involving 1115 patients.
Main Results:
- The mean WBC monitoring rate across responding sites was 54%.
- Academic detailing was associated with a 17% increase in WBC monitoring rates (p=0.011).
- Provider education increased monitoring rates by 9% (p=0.037), and each additional intervention increased rates by 3.8% (p=0.005).
Conclusions:
- Physician-centered interventions, particularly academic detailing, are effective in improving WBC monitoring for DMF-treated patients.
- Implementing multiple interventions can further enhance monitoring adherence.
- These findings support targeted quality improvement strategies to mitigate risks associated with DMF therapy.
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