Best practice advisory (BPA) is an efficient electronic health record (EHR) tool that may increase disease screening among patients with autoimmune rheumatic disease (ARD), according to study findings published in Arthritis Care and Research.
Prior to initiation of biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs), screening of patients for pre-existing latent tuberculosis (TB), hepatitis B virus (HBV), and hepatitis C virus (HCV) is recommended. However, screening for these diseases prior to treatment initiation has been subpar. Investigators assessed the effects of an EHR support tool on screening compliance among patients with ARD.
The investigators implemented a quality improvement initiative that included patients with ARD aged at least 18 years who were treatment naïve to b/tsDMARDs or switched from one b/tsDMARD to another.
The screening tool used was best practice advisory (BPA), a computerized decision support system that informs the clinician of prior test results for TB, HBV and HCV within the EHR. Data were extracted to evaluate compliance before (pre-BPA period) and after (post-BPA period) BPA implementation.
A total of 968 patients were included in the study, with 711 patients in the pre-BPA period and 257 in the post-BPA period. Inflammatory arthritis was among the most common rheumatic disease (86%), and tumor necrosis factor and interleukin-17 inhibitors were among the most common b/tsDMARDs prescribed (52% and 15%, respectively).
A statistically significant improvement in the number of patients screened was found for TB (pre-BPA, 66% vs post-BPA, 82%; P <.001), HCV antibody or HCV viral load (pre-BPA, 60% vs post-BPA, 79%; P <.001), and hepatitis B surface antigen (pre-BPA, 51% vs post-BPA, 70%; P <.001), following implementation of BPA.
Compared with the pre-BPA period, the implementation of BPA more than doubled the number of patients who were appropriately screened for all 3 infectious diseases (22% vs 46%).
Multivariate logistic analysis found that in relation to clinician training level, fellows were significantly more likely to order testing for all 3 diseases compared with attendings during the pre-BPA period (P <.001).
Of note, the implementation of BPA doubled the odds of screening for all 4 tests when adjusted for age, sex and clinician training level (odds ratio, 2.22; 95% CI, 1.64-3.00).
Study limitations included potential overestimation of the impact of BPA, as some physicians may not have screened patients considered low-risk due to unspecified guidelines. Additionally, potential confounding is possible due to the observational nature of the study.
The study authors concluded, “While we considered patient safety our primary objective, cost effectiveness of screening all patients remains unclear, and a potential future direction. Efforts are underway to extend the use of BPA beyond rheumatology to other specialties such as dermatology, gastroenterology, neurology, and immunology to improve screening proportions across specialties.”
Disclosure: One or more of the study authors declared affiliations with biotech, pharmaceutical, and/or device companies. Please see the original reference for a full list of authors’ disclosures.
Baker H, Fine R, Suter F, et al. Implementation of a best practice advisory to improve infection screening prior to new prescriptions of biologics and targeted synthetic drugs. Arthritis Care Res (Hoboken). Published online June 29, 2023. doi:10.1002/acr.25181