Background/Purpose: Certain disease-modifying anti-rheumatic drugs (DMARDs) increase the risk of reactivation of latent tuberculosis (TB). While screening for latent TB prior to initiation of these DMARDs is recommended for a most patients, low rates of screening have been reported in national rheumatology registry data³. A prior study conducted in our rheumatology clinic at an academic tertiary referral center suggested that only 63% of eligible patients from 2013-2017 were screened for latent TB prior to DMARD initiation. We highlight our approach of implementing a pharmacy-integrated safety check to capture this key safety measure.

Methods: Analysis 1: In October of 2019, we implemented a new pharmacy-integrated workflow in which clinicians prescribe new oral or injectable DMARDs to the university specialty pharmacy which reviews cases for adequate TB screening. DMARD prescriptions were filled or routed to patients’ contracted specialty pharmacies only once adequate TB screening was completed unless the clinician specified otherwise. Analysis 2: Using SQL to extract data from the electronic health record (EHR) for the calendar year 2020, we generated a list of patients eligible for TB screening which served as the denominator in calculating our TB screening rate. First, all qualifying DMARD prescriptions were identified. We excluded refills, patients switching between DMARDs, and patients with a history of TB using historic prescription data and information from the past medical history of problem list. Adequately screened cases (numerator) had a result for an interferon gamma release assay or purified protein derivative test within 365 days prior to or 60 days after the DMARD prescription start date We validated all inadequately screened cases by manual chart review.

Results: Analysis 1: In 2020, 97 new qualifying DMARD prescriptions were routed through our workflow. In three cases, the medication was not started due to patient or clinician preference or lack of insurance coverage. These were excluded from the denominator. In two instances, the clinician overrode the requirement for TB screening within 365 days as it had been performed with the prior 18 months. Analysis 2: EHR data extraction identified 159 cases in 2020 eligible for TB screening, and 130 were screened adequately for a TB screening rate of 82%. Differences in numbers of eligible patients in EHR data versus through the workflow were analyzed via manual chart review. Chart review also suggested reasons for inadequate screening including prior TB screening outside of the defined timeframe, treatment hiatus, and prescription of an infusion.

Conclusion: Our intervention was associated with a significant improvement of 19% in our clinic’s TB screening rate compared to historic rates. Reviewing EHR data identified additional reasons for missed screening. These reasons for missed screening may inform future process improvement cycles related to capturing this key safety measure.

« Back to ACR Convergence 2021

ACR Meeting Abstracts - https://acrabstracts.org/abstract/implementation-of-an-interprofessional-safety-check-to-screen-for-latent-tuberculosis-at-an-academic-tertiary-referral-rheumatology-clinic-increased-screening-rates-compared-to-historical-levels/