Non-visit electronic consultations (NVCs) are an important component of care for VA patients requiring sub-specialty consultation but not requiring urgent face to face evaluation. Here we specifically analyzed referrals for monoclonal gammopathy of undetermined significance (MGUS), since this is a diagnosis that requires ongoing surveillance once identified. It is an ideal model to study utilization and effectiveness of NVCs over time.
We identified 615 electronic hematology consultation encounters from 1/1/11-12/31/11 at our institution. Of these, 37 (6%) were consults for MGUS. Patient records were evaluated up to 5 years following the original consultation. We found that 16% (6/37) of MGUS patients subsequently had a face to face evaluation. 4 of these were due to onset of malignancy (3 multiple myeloma and 1 non-Hodgkin lymphoma). Over the 5 year study period, 51% (19/37) have been one-time consults while 32% (12/37) have utilized multiple NVCs. Typical recommendations at our institution for MGUS include yearly SPEP, serum free light chain assessment, and a baseline skeletal survey. Bone marrow biopsy is not routinely recommended for low-risk patients. Surveillance and re-consultation by a specialist is at the discretion of the referring provider.
22 of 37 MGUS patients had a documented skeletal survey. Of the 15 without evaluation, 7 had M-protein values that were only positive by immunofixation, while 4 were IgM cases. We do not routinely promote DEXA, though 14% of MGUS patients also had a DEXA (for any reason). In addition, the majority of MGUS patients (28/37) were found to have documented 25-OH vitamin D levels. Among these, only 4 had a mean vitamin D level that would be considered deficient (under 20 ng/mL).
Overall, we describe a cohort of MGUS patients initially identified via electronic consultation at our institution. With an average study follow-up of only 4-5 years, we identified 4 cases of malignancy (10.8% of MGUS NVCs), demonstrating the importance of careful evaluation of MGUS cases referred for specialty consultation. Areas of uncertainty that require further attention include: 1) skeletal surveys in patients with scant monoclonal protein, 2) routine promotion of DEXA and 3) targeted vitamin D supplementation practices among MGUS patients.
