Telehealth based virtual consult visits and in-person consult visits provide comparable time to HLA-typing and preliminary donor search in patients referred for allogeneic hematopoietic cell transplantation

Abstract

Abstract Introduction: Allogeneic hematopoietic cell transplantation (alloHCT) is the only curative therapy for patients with high-risk hematologic malignancies. However, many patients do not proceed to alloHCT due to lack of disease control, comorbidities or systemic barriers to access HCT. In the state of Oregon, Oregon Health & Science University (OHSU) is the only adult alloHCT center and given its significant catchment area, distance is a potential barrier to access alloHCT consultation and treatment. Here, we report descriptive outcomes of a quality improvement (QI) initiative of early human leukocyte antigen (HLA) typing with preliminary unrelated donor (pURD) search, via a structured telehealth consultation model, for all patients referred to the OHSU adult HCT program. Methods: A multidisciplinary team including BMT physicians, nurse navigators, insurance authorization specialists, and donor search coordinators, collaborated in process development and execution of this QI initiative. The QI interventions set out to offer a telehealth consult to all referrals and a mail-in HLA typing kit to external referrals who lived farther than 30 miles. Zip codes were used to calculate distance from patient's residence (PR) to the transplant center (TC) at OHSU. Transplant indication (TI) was defined based on disease specific risk stratification. The primary goals were to ensure availability of preliminary donor search results at the consult visit, assess the role of telehealth in reducing time to transplant, and evaluate referral patterns across the greater catchment area. Results: We reviewed 216 referrals who received the planned interventions during 2024 with at least 3 months of follow-up for the last patient in the cohort, allowing time to proceed to HCT. Indication for alloHCT referrals were Acute Myeloid Leukemia (AML, 43.98%), Acute Lymphoblastic Leukemia (ALL, 9.26%), Myelodysplastic Syndrome (MDS, 12.96%), Lymphoma (7.87%), Chronic Myeloid Leukemia (CML, 6.02%), Myelofibrosis (MF 8.33%), Chronic Myelomonocytic Leukemia (CMML, 3.70%), and other (7.88%). There was predominance of male patients (56.94%), Caucasians (74.54%) and private insurance users (65.28%). There were 97 internal referrals (44.91%) and 119 external referrals (55.09%). Consultation visit types included 2 phone visits (PV, 0.92%), 71 virtual visits (VV, 32.87%), and 141 in-person visits (IPV, 65.28%). Two patients did not attend their VV due to lack of internet access and loss of follow up (0.93%). The median distance from patient residence (PR) to transplant center (TC) for all consultations was 44 miles (4 – 2609), with 145 (4 – 2609) miles for VV and 22 (4 – 2561) miles for IPV, with some patients coming from other states. HCT was recommended in 146 patients (67.59%), of which 89 patients received HCT (60.96%) and 57 patients (39.04%) did not proceed to transplant. Disease based distribution of patients who proceeded to HCT was predominantly AML (57.30%), followed by ALL (12.36%), MDS (10.11%), Lymphoma (7.87%), CML (5.62%), MF (2.25%), CMML (2.25%), and other (2.24%). The median distance from PR to TC for all transplanted patients was 33 (4 – 2609) miles, with 175.5 (7 – 2609) miles for VV and 21 (4 – 2561) miles for IPV consults. For all patients, the median time is comparable for TI to referral placed (37 vs 33 days), TI to consult visit (70 vs 66 days), TI to HLA typing (45.5 vs 39 days), and TI to prelim donor search (58.5 vs 59.5 days) for VV vs. IPV, respectively. For those who proceeded with HCT, the median time remained comparable for TI to referral placed (30.5 vs 33 days), TI to consult visit (68 vs 66 days), TI to HLA typing (24.5 vs 29 days), TI to prelim donor search (49 vs 50 days), consult to transplant (95 vs 96 days) and TI to transplant (172 vs 176 days) for VV vs. IPV, respectively. Conclusion: Implementation of a structured telehealth-based model, with a multidisciplinary workflow was effective for early HLA typing and pURD search. The use of telehealth can provide similar access and level of care to HCT evaluation and transplant as IPV, particularly for patients facing barriers to care via IPV due to ongoing treatment, comorbidities, poor functional status or lack of transportation and caregiver support. Future work will expand the current model to include early social worker interventions and compare resource utilization (e.g., clinic visits, travel costs, staffing) between telehealth and in-person pathways.