Best Practices for Infection Screening
Reducing risks for patients with autoimmune rheumatic disease prior to starting new DMARD prescriptions
By Hailey Baker, MD, MS, & Abhijeet Danve, MBBS, MD, MHS
Why was this study done? Starting biologic and small molecule disease-modifying anti-rheumatic drugs (DMARDs) in patients with undiagnosed hepatitis or tuberculosis (TB) carries an increased risk of morbidity and mortality. Guidelines recommend screening for hepatitis B virus (HBV), hepatitis C virus (HCV) and TB prior to initiation of DMARDs; however, adherence to these guidelines varies widely. Best practice advisories (BPAs) are built into the electronic medical record (EMR) and can be used to notify clinicians when a patient does not have recent infectious screening tests. We implemented a BPA to alert providers of potential gaps in screening and assess the impact of the BPA on screening proportions for TB, HBV and HCV.
What were the study methods? We included patients 18 years or older with an autoimmune rheumatic disease (ARD) and at least one visit to our rheumatology practice between Oct. 1, 2017, and March 3, 2022. We assessed screening practices with new DMARD prescriptions for HBV, HCV and TB before and after implementation of the BPA on Dec. 1, 2020. We performed multivariable logistic analyses including patient characteristics (age, sex, and race and ethnicity) and clinician training level (i.e., attending, fellow or advanced practice registered nurse [APRN]).
What were the key findings? We observed an approximate 20% increase in screening proportions for TB, HCV, HBcAb and HBsAg after implementation of the BPA. Multivariable logistic analysis showed that training level, patient age and patient sex all influenced screening proportions prior to the BPA, but there was no statistically significant influence of any variable after implementation of the BPA. Implementation of the BPA increased the adjusted odds of screening by 2.2 to 2.5 times when adjusted for age, sex and clinician training level.
What were the main conclusions? Our pre-BPA screening proportions were low (ranging from 32% for HBcAb to 66% for TB), similar to other studies. A BPA has the ability to improve patient safety, enhance clinician efficiency and eliminate biases in screening.
What are the implications for patients and clinicians? Screening for HBV, HCV and TB prior to DMARD initiation allows patients to have their potentially undiagnosed infections treated to reduce risk of infectious complications with immunosuppression. A BPA uses technology built into the EMR to reduce the burden on clinicians during busy clinics. Alerts like the BPA may contribute to clinician pop-up fatigue, but a post-BPA survey showed that respondents felt it helped them manage their patients more efficiently (5 of 9 responders).
