Association of Different Interventions to Increase Leukocyte Testing During Treatment With Dimethyl Fumarate

Abstract Background: 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 VA Medication Use Evaluation Tracker (MUET) initiative which provides VA facilities with a list of patients prescribed DMF therapy without a documented white blood cell count (WBC).Methods: We identified 118 VA facilities with patients treated with DMF from 1/1/2016 through 9/30/2016. We determined WBC measurements within three months of the first filled prescription. The lead pharmacist at each facility was surveyed asking if any of seven intervention types 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).Results: The facility response rate for the survey was 78% (92 of 118 facilities). For the 92 included facilities (1,115 patients) the mean rate of WBC monitoring was 54%. Use of the at-risk patient lists was noted in 55% (51/92) of facilities. In multivariate analysis, only academic detailing and provider education remained significantly associated with higher WBC monitoring. From a base WBC monitoring rate of 46%, 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).Conclusions: Interventions focused on the physician, including academic detailing, were associated with improved WBC monitoring for patients at risk for leukopenia from dimethyl fumarate treatment.