Background/Purpose:  Hydroxychloroquine (HCQ) is a widely used rheumatologic drug that carries a risk for irreversible retinal toxicity. The incidence of adverse effect increases to greater than 1% beyond the five year mark and screening is recommended annually beyond this time. This risk is mitigated through screening exams; 10-2 visual field testing (VF) and spectral domain optical coherence tomography (SD-OCT). In our practice setting, several visits to ophthalmology are needed to complete the screening. First the patient makes an appointment for consultation with the ophthalmologist, who then orders the testing to be done at a later date and finally the results are reviewed with the ophthalmologist.

Methods:   To analyze the problem, the electronic medical record (EMR) was reviewed to identify the patients who have been on HCQ for five years or more. These patients were then cross-referenced with system procedure codes for the American Academy of Ophthalmology recommended monitoring options for HCQ related retinal toxicity in addition to the 10-2 visual field testing (VF) and (SD-OCT). Letters were sent to patients with brief education and a request to schedule an appointment. The investigators collaborated with the ophthalmology department to create a work flow for HCQ screening. Schedulers were educated about methods of screening and coached to schedule the required testing without an initial ophthalmology visit. This process streamlined the usual ophthalmology scheduling process, which involves seeing the ophthalmologist initially followed by a return visit(s) for the recommended screening and a return visit for test review.

Results:   Of the 183 patients on HCQ longer than 5 years, 58.4% have not been screened. Chart review unearthed 183 patients on HCQ longer than five years. 148 of these patients did not have billing codes for screening tests in the EMR. Manual chart review revealed an additional 41 screened patients. Overall, the increase in monitoring for patients within the system was increased by 41.8%.  

Conclusion:   The pre-intervention process for HCQ monitoring was prohibitive for patients to receive timely monitoring. When patients called the ophthalmology scheduling department they were first scheduled with an ophthalmologist to establish the goal for the appointment. This initial visit is unnecessary if the only purpose of the visit is HCQ screening, as the guidelines are very specific. Further, the wait time to see an ophthalmologist is approximately three months or longer. There is additional wait time for an appointment for the visual field and SD-OCT testing post appointment. Tests meant to be performed annually could take four to six months to schedule and complete. Patients who identify themselves as requiring an ophthalmology appointment for the sole purpose of HCQ monitoring should be scheduled immediately for VF and SD-OCT without an initial visit with an ophthalmologist. The cumbersome appointment process was unknown to rheumatologists. It was only in working in an interdisciplinary fashion that the process was able to be more patient centered and timely.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/it-takes-two-an-interdisciplinary-approach-to-increasing-hydroxychloroquine-screening-adherence/