Improving Infection Screening in Patients With Autoimmune Rheumatic Diseases Starting Biologics

The importance of screening patients for underlying chronic infections before initiating immunosuppressive medications is well known, yet clinician adherence to screening guidelines varies widely. In a new study, researchers developed an automated computerized decision-making support system in the form of a best practice advisory (BPA) and evaluated the impact of this new tool on pre-treatment screening.

The findings were published in Arthritis Care & Research.

Biologic and targeted synthetic disease modifying anti-rheumatic drugs (DMARDs), which are usually immunosuppressants, are commonly used by rheumatologists to treat patients with various autoimmune inflammatory diseases, says Hailey Baker, MD, a researcher in the study and clinical fellow in rheumatology at Yale School of Medicine (YSM). But prescribing these medications to patients with preexisting hepatitis or tuberculosis can lead to adverse, even life-threatening complications.

“In rheumatology practice, we have to be very careful about the risks and side effects of immunosuppressive medications, so this quality improvement initiative was an effort we decided to undertake,” said Abhijeet Danve, MD, MHS, associate professor of medicine (rheumatology, allergy and immunology) and co-chair of the Quality and Safety Council for the Section of Rheumatology at YSM.

Prior to implementing the BPA, infection screening rates were low due to various factors including clinician preferences, vague screening guidelines, and different order names for the same lab test in the electronic medical record system, Danve explains. “We thought we should automate this process so that the physician ordering the biologic would be alerted to the patient’s most recent test results for tuberculosis, hepatitis B, and hepatitis C,” he said. “The computer pop-up we created lets the physician know whether the patient has been tested, if the test results are normal, and also allows the physician to order the test if it has not been done.”

The study examined 711 patients treated over three years before implementation of the BPA and 257 patients treated over two years post-BPA implementation at outpatient rheumatology practices at the Yale New Haven Health System (YNHH). Researchers found that the BPA implementation was associated with a 66% to 82% increase in screening for tuberculosis, a 60% to 79% increase in screening for hepatitis C, and a 51% to 70% increase in screening for hepatitis B.

In addition to improving patient safety, Danve says, researchers sought to boost physician efficiency and workflow. Lisa Suter, MD, professor of medicine (rheumatology), and Vaidehi Chowdhary, MD, associate professor of medicine (rheumatology, allergy and immunology), contributed substantially to the study design and ongoing modification of the BPA.

The successful initiative has become standard of care in YNHH rheumatology practices, according to Danve, and is also being used by pharmacists. “We now have a great system for ensuring patient safety that can be adopted by clinicians across Yale and beyond,” he said.

The team of researchers also included Rebecca Fine, MD, Fenn Suter, Heather Allore, PhD, Betty Hsiao, MD, Elizabeth Lavelle, Ping Chen and Richard Hintz.