ASCO 2014 - Abstract 627

ASCO 2014. Abstract 627. An electronic prompt prior to myelosuppressive therapy to improve hepatitis B virus screening.

Jordan J. Feld, Lisa K. Hicks, Joshua Juan, Truong Judy, Urszula Zurawska, Angie Giotis, Kelvin K. Chan; University Health Network, University of Toronto, Toronto, ON, Canada; St. Michael's Hospital, University of Toronto, Toronto, ON, Canada; University Health Network, Toronto, ON, Canada; Odette Cancer Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; St. Joseph's Health Centre, Toronto, ON, Canada; Sunnybrook Health Sciences Centre, Toronto, ON, Canada

Background: Hepatitis B virus (HBV) reactivation is a potentially fatal and yet preventable complication of myelosuppressive therapy. However, HBV screening rates have been low despite the recommendation from the Centre of Disease Control (CDC) to screen all patients prior to myelosuppressive therapy. We evaluated the effectiveness of an electronic prompt on HBV screening rates.

Methods: An electronic prompt was established in Nov 2010 at a large academic oncology centre in Toronto (study centre). The electronic prompt reminded ordering physicians to order HBV surface antigen (HBsAg) at the time of booking a new patient’s first chemotherapy electronically. For physicians who agreed, HBsAg was automatically ordered. The prompt was not implemented at another large academic oncology centre in Toronto (control centre). Both centres received the same educational rounds in Nov 2010. The primary endpoint was the rate of HBV screening. Actual HBV screening rates were determined in both centres both prior to the intervention (Nov 2009 to Oct 2010) and during the intervention (Nov 2010 to Oct 2011). Multivariable logistic regression with random effects was conducted to assess the effect of the electronic prompt adjusting for potential confounders and clustering of patients by physicians. 

Results: 6,116 patients received first chemotherapy during the study period (2,095 study centre, 4,021 control center). In the pre-prompt period, the screening rate was 17% in the study centre and 25% in the control centre. In the prompt period, the screening rate increased to 61% in the study centre and was unchanged at 25% in the control centre. The overall screening rate for patients with hematological (heme) malignancies was higher (62.3% vs. 20.4% in non-heme patients, p<0.0001). After adjusting for study period, centres and heme malignancies, the electronic prompt improved the HBV screening rate significantly (odds ratio 11.0, 95% CI 8.3-14.7, p<0.0001), which remained significant adjusting for clustering of patients by physicians (p<0.0001).

Conclusions: An electronic prompt increased the rate of HBV screening, however screening rates remained relatively low. Educational rounds did not appear to improve the HBV screening rate. 

Hepatitis B (HBV) reactivation is a potentially serious but largely preventable complication of chemotherapy. HBV replication is usually controlled by the intact immune system. During chemotherapy, immune control may be lost leading to a marked increase in viral replication, which may be associated with severe or even fatal hepatitis. Fortunately well-tolerated oral antiviral almost entirely prevent HBV reactivation provided they are started before or with the start of chemotherapy. This is an important issue, particularly in large urban centers where HBV prevalence may be upwards of 2%. The challenge is that to prevent HBV reactivation, one must first identify HBV. Most patients are entirely asymptomatic and the majority is actually unaware that they are infected. Hence it falls on the oncology team to identify those with HBV. The Centers for Disease Control and Prevention in the US recommends screening all patients before immunosuppressive therapy for Hepatitis B surface antigen (HBsAg). However, screening rates remain consistently low, perhaps in part because other societies, such as ASCO, are less clear on screening recommendations. ASCO suggests a risk-factor-based approach, but unfortunately risk factor-based screening has proven very ineffective in almost all areas of medicine, including HBV. This study introduced an automated prompt to remind physicians to order HBsAg prior to starting chemotherapy. They did find that the prompt increased screening rates from 17% at baseline to 61% with the prompt, which was significantly better than what occurred at a ‘control’ hospital with no prompt. Although this was clearly a marked improvement, a 61% screening rate is still rather low. Notably both groups had a pre-study educational intervention, which did not change the screening rate at all. The message from this study is that simply making oncologists aware of the issue is not enough and unfortunately, although a prompt improved screening rates, they were still suboptimal. This study suggests that a more definitive ‘hard-stop’ approach to HBV screening is likely the only way to get all patients screened so no one dies of this preventable problem anymore.
— CARE Oncology Faculty