National Practice Patterns in Tuberculosis and Hepatitis Screening Prior to Tumor Necrosis Factor Antagonist Therapy in Veterans with Inflammatory Bowel Disease

Abstract

Purpose: Tumor necrosis factor antagonists (anti-TNFs) are effective in treating inflammatory bowel disease (IBD), but may cause reactivation of latent tuberculosis (TB) and hepatitis B virus (HBV). Practice guidelines and IBD performance measures recommend screening for latent TB and HBV prior to anti-TNF initiation. However, the performance rates of TB and HBV screening prior to anti-TNF initiation are unknown. The aim of this study is to evaluate the prevalence and determinants of TB and HBV screening prior to anti-TNF initiation in a national cohort of veterans with IBD. Methods: We identified a cohort of Veterans Affairs (VA) users with IBD diagnoses during fiscal years 2003-2011, using the national VA administrative data sets. Patients with IBD were identified by a previously validated algorithm using International Classification of Diseases, 9th Revision, diagnosis codes for Crohn's disease (CD) or ulcerative colitis (UC). Among those patients, those with filled prescriptions for infliximab, adalimumab, and certolizumab pegol were evaluated. The anti-TNF start date was defined as the date of the first filled anti-TNF prescription. TB screening was defined as the performance of a purified protein derivative test or QuantiFERON-TB gold test within 6 months prior to anti-TNF start date. HBV screening was defined as testing for HBV surface antibody, core antibody, or e antigen within 1 year prior to anti-TNF start date. Determinants of screening were identified by univariate and multivariate analyses. Results: A total of 3,357 IBD patients were identified with filled anti-TNF prescriptions. Approximately 72% of subjects received TB screening, and only 24% of subjects received HBV screening prior to their anti-TNF start date. In multivariate analyses, patients who live in rural areas were significantly less likely to be screened compared to those in urban areas for TB (odds ratio [OR] 0.72; 95% confidence interval [CI] 0.54-0.95) and HBV (OR 0.72; 95% CI 0.52-0.98). Patients who received care at facilities with an academic affiliation were more likely to have received screening for TB (OR 1.49; 95% CI 1.31-1.95) and HBV (OR 1.97; 95% CI 1.33-2.92). Patients who received care at a facility with a high volume of IBD patients on anti-TNFs (top quintile) were more likely to have received screening for HBV compared to patients who received care at a low-volume facility (OR 2.16; 95% CI 1.59-2.93). Conclusion: Screening prior to anti-TNF initiation for TB, and especially for HBV, is low in a national cohort of veterans with IBD. Receipt of care at urban, academic-affiliated, high-volume IBD facilities is associated with higher rates of screening. Identification of TB and HBV screening processes at these high-performing facilities may serve as models for other facilities. Disclosure - Dr. Hou- Speakers Bureau: UCB pharma, Abbvie.