PC2056: Clinical Decision Support to Improve Hepatitis B Screening Rates Prior to Rituximab Use in Patients with Rheumatic And/or Renal Diseases

Purpose/Objectives: Immunosuppression with rituximab, often used for the treatment of rheumatic and renal immune mediated diseases, increases the risk of hepatitis B virus (HBV) reactivation in patients with chronic or past HBV infection. Screening is recommended prior to rituximab therapy, which requires hepatitis B surface antigen (HBsAg), hepatitis B anti-surface antibody (anti-HBsAb) and total hepatitis B anti-core antibody (total anti-HBcAb). We aimed to increase the rates of complete HBV screening and collection of individual screening components by 50% above the baseline in our practice.

Design/Methods: This quality improvement project was conducted from November 2020 to March 2022 at a tertiary care pediatric hospital system. Rates of pre-rituximab complete HBV screening and collection of individual screening components (HBsAg, anti-HBsAb, total anti-HbcAb) were tracked in pediatric patients ( < 21 years) with rheumatic and/or renal diseases requiring rituximab or biosimilars for the first time. Baseline pre-intervention rates from September 2019 to November 2020 were obtained. Electronic Health Record (EHR) interventions included: 1. A dot phrase to document screening and remind providers of screening components (March 2021); 2. Modification of outpatient rituximab therapy plans to include a nursing communication and screening orders (October 2021); 3. Incorporating instructions for screening, available results, and screening orders into the rituximab inpatient order set (January 2022). Non-EHR interventions included: 1. Educational presentations (November 2020, February 2021) and 2. Posted signs at provider clinic workspaces (July 2021). Data were extracted via electronic report and confirmed through chart review. Statistical process control charts were developed to monitor performance. Pre- and post-intervention screening rates (before/after November 2020) were compared using Fisher/Chi-square tests.

Results: One-hundred-and-sixty-three patients were included in the analysis (pre-intervention n= 84; post-intervention n= 79). Overall rates of complete HBV screening (6% vs 40.5%; p < 0.001), HBsAg collection (59.5% vs 74.7%; p= 0.046), anti-HBsAb collection (14.3% vs 50.6%; p < 0.001), and total anti-HBcAb collection (8.3% vs 45.6%; p < 0.001) were significantly higher in the post-intervention period. 28 patients (35.4%) in the post-intervention period were HBV-non-immune (anti-HBsAb negative), for whom primary or booster vaccination was recommended. Several data points above the upper control limit were identified for complete screening, total anti-HBcAb collection and anti-HBsAb collection (Figure).

Conclusion/Discussion: Screening for chronic and past HBV infections should be conducted in patients starting rituximab therapy. Clinical decision support combined with educational interventions significantly increased the rates of screening for chronic and past HBV infection in patients with rheumatic and/or renal disease in our practice, although overall post-intervention screening rates were below the goal. This should be cautiously interpreted, as low screening rates soon after project initiation likely influenced these results. Moreover, the increment in screening rates noted during the late post-intervention period is anticipated to continue post-project completion, owing to the use of EHR-based tools.