Background Established guidelines from a variety of societies are vague and do not necessarily agree about recommendations for Hepatitis B & C (Hep B/C) screening prior to initiation of immuno suppresive medications (ISM)1.
Objectives This study was designed to better understand the existing practices for Hep B/C screening among rheumatologists. There were two primary aims: a) Determination of the actual performance measures (PM) (i.e. screening rates prior to ISM), as well as factors significantly associated with the likelihood of screening, among rheumatology patients and b) Determination of the self-reported PM's among rheumatologists for each ISM and the associated factors.
Methods For actual PM's, retrospective chart review study of 200 patients seen in the rheumatology clinic was done. Data collected included demographics, total number, name and dose of ISMs currently used, and if tests (and results) for Hep B/C were ordered prior to ISM initiation. ISM use was defined as current use of any ISM including corticosteroids. We defined Significant ISM (SISM) use as a) current use of prednisone ≥7.5 mg/day with hydroxy-chloroquine (HCQ), or (b) ISM use other than only HCQ. For self-reported PM's, a survey study was designed using Survey Monkey & e-mailed to 1200 rheumatologists. Data collected included demographics, board certification, number of years out of fellowship, setting of practice, number of patients seen in a month and hours of clinical care provided per week along with Hep B/C screening prior to each ISM. Options were scaled and included the following options: routinely screened or screened only if at high risk or did not routinely screen prior to starting ISM. Chi square test was used to compare discrete variables, while t tests were used to compare continuous variables.
Results Retrospective chart study: A total of 200 patients were included, Mean age: 40 years, 85% female; 16% were on biologics and 82% were on SISM. Actual performance measures (PM) for Hep B/C screening ranged between 28–56% prior to ISM initiation. PM's for Hep B & C prior to ISM were as follows: biologics 72% & 69%; Anti-TNF 81% & 71% and SISM 62% & 57%, respectively. Age correlated negatively whereas number of ISMs correlated positively with Hep B/C screening. Survey study: Survey was mailed to 1200 rheumatologists, response rate: 20% (n=251), Nearly 60% were >15 years out of fellowship, 46% practicing academics, 43% saw >80 patients/week requiring ISM, and 74% spent >20 hours/week in clinical care. Self-reported PM's were varied for routine Hep B/C screening and ranged between 8–90% prior to ISM therapy. Age & years out of fellowship correlated inversely whereas number of patients seen per month correlated positively with screening.
Conclusions Actual Hep B/C screening rates are low and range from 28–56% prior to initiating any ISM. In comparison, self-reported screening rates vary from 8–90% reflecting the varied physician screening practices with regards to various ISM. There is a clear need for consistent guidelines regarding screening for hep B/C in the presence of ISM therapy, and to improve awareness among rheumatologists regarding the risks of reactivation, and the need for screening and vaccination in at-risk patients.
Vassilopoulos D, Nat. Rev. Rheumatol.8,2012,348–357
Disclosure of Interest None declared
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