Improving Providers' Knowledge of the Benefits of Early Identification of Amyloidosis

Background: Transthyretin amyloidosis (ATTR) is an underdiagnosed systemic infiltrative disease that may involve the heart and cause heart failure. The median survival of cardiac amyloidosis is around 3.5 years without treatment. Earlier diagnosis is critical, as novel therapies for cardiac amyloidosis improve mortality. Extracardiac manifestations commonly develop ~5- 10 years prior to the onset of heart failure including bilateral carpal tunnel syndrome, biceps tendon rupture, and lumbar spinal stenosis are characteristic. Local Problem: The University of Utah Orthopedics Department performs >500 surgeries per year for spinal stenosis, presenting an opportunity to screen for amyloidosis. The University of Utah Hospital does not currently have a screening tool for patients with high-risk symptoms of ATTR-CM. Methods: A quality improvement project was developed to increase screening rates for amyloidosis among patients with spinal stenosis. A pre-educational survey was administered to orthopedic providers to determine baseline knowledge of amyloidosis. An educational presentation was presented to participating orthopedic providers. A screening tool was implemented over an eight-week period for all patients undergoing spinal stenosis surgery. Among patients with positive screening, orthopedic surgeons obtained a biopsy of ligamentum flavum to evaluate the presence of amyloid. After an eight-week period, a post-implementation survey was distributed to all orthopedic providers to determine the usability, feasibility, and satisfaction of the quality improvement project. Intervention: content experts developed an early identification screening tool to determine the risk for amyloidosis. Results: Post-intervention, we found that 72% (n=5) of orthopedic providers were ‘very comfortable' with the orthopedic manifestations of amyloidosis compared to 57% (n=4) of providers feeling very uncomfortable prior to this project. All participants (n=7) believe they have a role in the early identification of amyloidosis and are likely to continue to biopsy patients who screen positive for high-risk amyloidosis. Twenty-five percent (n=26) of patients screened positive and underwent spinal stenosis surgery. Biopsies were obtained in 39% (n=10) of the 26 patients. Fifty percent (n=5) of the 10 biopsies were positive for amyloid. Conclusions: This quality improvement project showed a lack of knowledge on high-risk symptoms for amyloidosis among orthopedic providers, but educational presentations and screening tools help close this knowledge gap. Five patients were identified with amyloidosis prior to heart failure that would not have been known prior to this project. Providers found this project useful and plan to continue using the screening tool. There is an opportunity for multidisciplinary collaboration to diagnose and treat amyloidosis with the goal of preventing heart failure.