Systems-Based Care Improvements to Optimize BTK Inhibitors in Chronic Lymphocytic Leukemia Vary in the Community Setting

BACKGROUND: The management of chronic lymphocytic leukemia (CLL) has evolved considerably, including recent approvals of targeted therapies that significantly expand the treatment landscape and improve patient outcomes. As more drugs and combinations join the therapeutic armamentarium, it is increasingly urgent to understand the evidence for each and select the right drug for the right patient. However, too many patients do not receive proper testing to guide therapy and large numbers receive inappropriate chemotherapy even after testing. To resolve real-world barriers to the integration of guideline- and evidence-based care, a 4-phase, implementation-science, systems-based initiative was developed.

METHODS: The initiative was submitted and approved by a centralized institutional review board. Phase 1 included baseline data analyses, phase 2 included a data-informed tethered educational initiative, phase 3 was a plan-do-study-act follow-up, and phase 4 was dissemination of findings. Approved materials were used in collaboration with Premier to identify 3 appropriate community cancer centers to engage in the initiative with a minimum of 25 active patients with CLL (regardless of disease stage). The 3 centers completed 25 chart extractions following the protocol’s inclusion criteria, 25 team surveys, and 10 patient surveys, constituting the baseline data in phase 1 of the initiative. The data was presented to each center by a CLL expert and benchmarked against national guidelines during a virtual roundtable. The CLL experts provided guidance to each center to develop action plans designed to address specific areas of improvement. The baseline data collected in phase 1 in addition to the action plan tracking for the 3 centers will be presented.

RESULTS: The participating community cancer centers were diverse in both practice type and geography. Across the three centers, we collected data from 141 patient charts, 70 team member surveys, and 31 patient surveys. The analysis of the data across the three centers revealed persistent challenges in the community setting. As it relates to molecular testing, 20% of all charts reviewed did not contain a testing report with approximately 50% of team members noting that testing for key high-risk cytogenetics was always performed before initiating therapy. Only 31% of team members correctly risk-stratified a patient, and only 14% of patients reported that testing was ordered, and results were received before treatment was determined. Within the findings from the initiative, we saw disparities in perceived vs actual utilization of targeted treatment based on chart data vs survey data. Team members from all 3 centers consistently reported higher utilization of targeted therapy than shown in the chart data. We also determined disparities between provider and patient perceptions of the initial therapy they were receiving. Roundtable discussions revealed a misnomer in patient education labeling (e.g. chemo-teach) that influenced these perceptions.To date, all sites have achieved significant progress with their action plans and continue to work through challenges to meet 100% of center-specific goals.

CONCLUSIONS: The systems-based initiative has resulted in meaningful advancements in practice, setting new standards for testing and patient-centered care, and provided educational resources for community-based teams. Action-plan domains provide solution-oriented guidance for other community-based practitioners and teams for ease of implementing best practices in the wider hematology/oncology community. The educational initiative and overall impact continue to be evaluated through the course of all 4 phases.

This initiative was supported by an educational grant from AstraZeneca Pharmaceuticals.