(NSO-02) Improving Capacity in the Malignant Hematology Day Unit by Increasing Subcutaneous Immunoglobulin Replacement Treatment in the Community

Intravenous immunoglobulin (IVIG) is a therapy used to treat patients with secondary immunodeficiency. A subcutaneous home-based immunoglobulin treatment (SCIG) has proven to be as effective as the hospital-based intravenous form. There is an opportunity to increase SCIG referrals across the Malignant Hematology Program, particularly for patients diagnosed with secondary immunodeficiency whereby the majority of patients have multiple myeloma. The aim was to establish a new best practice standard for treating eligible patients with secondary immunodeficiency using SCIG instead of IVIG. The transition of eligible patients aims to alleviate patient burden, reduce in-clinic infusion times, and optimize nursing resources.

Methods: As part of the initial needs assessment, clinical groups were consulted to provide feedback on their use of IVIG and SCIG. Interventions were implemented using a multi-phase approach that was carried out over three Plan-Do-Study-Act (PDSA) cycles. Family of measures were analyzed for both the outcome measures and the process measures. For the data analysis, aggregate monthly SCIG referral numbers were provided by the SCIG community programs on a quarterly basis. Once the electronic referrals to both community partners were built, a data report in the institution's health informatics system was developed to automatically track SCIG electronic referrals made in real time.

Results:

Results of IVIG use was split into two groups: new patients receiving IVIG and ongoing patients. The average number of first time IVIG treatments decreased, while the number of patients with at least 1 previous month of IVIG treatment increased. In analyzing chair time in MHDU, patients receiving both short and long IVIG treatment increased. SCIG referrals accounted for nursing hours saved and significant annual cost savings.

Conclusions: SCIG referral increased in response to rising IVIG demand, driven by novel therapies (e.g., Chimeric antigen receptor (CAR) T-cell therapy, bispecific T-cell engagers). While the intervention improved SCIG uptake, it did not reduce monthly IVIG utilization. The number of IVIG patients increased largely because early PDSA cycles targeted new referrals rather than existing IVIG users. Barriers to SCIG adoption—such as needle phobia, lack of social support, and self-administration challenges—persisted. These require targeted strategies for patient education and support.

The ongoing expansion of novel therapies alongside evolving eligibility criteria for multiple myeloma patients increases IVIG demand and offsets gains in reducing overall utilization. This has implications for outpatient resource strain and can delay or limit access to other treatments.

Patient burden remains high with monthly clinic visits impacting quality of life. Transitioning appropriate multiple myeloma patients to SCIG can alleviate this, but broader implementation requires addressing logistical and patient-centered barriers to inform a more sustainable model of supportive care.