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Abstract
Introduction/Background In 2020, the American Society of Clinical Oncology recommended universal hepatitis B virus (HBV) screening prior to chemotherapy to reduce risk of reactivation and associated morbidities. In gynaecologic oncology patients initiating chemotherapy at the Juravinski Cancer Centre, baseline screening rate over 6 months was 1.1%; our aim was to increase this to 70% over 6 months and compare real-world efficacy of risk factor-based vs. universal screening.
Methodology This interrupted time-series study used Model for Improvement methodology. Four interventions were implemented in iterative Plan-Do-Study-Act cycles to address identified screening barriers: provider education, testing protocol standardization, integration with clinical workflow, and biweekly feedback reports. Retrospective chart review collected process and outcome measures (analyzed on statistical process control/run charts), and demographic and disease data including Centers for Disease Control (CDC) hepatitis risk factors.
Results From Dec 1/20-Nov 30/21, there were 381 gynecologic chemotherapy initiations. The proportion of physicians screening increased from 0% to 100%, and HBV monthly screening rates increased from 1.1% to 72.2% by month 9, sustained for 4 months at last analysis. The integrated clinic screening protocol and feedback report interventions were associated with increased screening rates. Of 330 unique patients initiating chemotherapy, 175 were screened (53%); 60.9% had ≥1 risk factor. HBV surface antigen was non-reactive in all screened, but anti-HBV core antibody was reactive in 5 (2.9%), indicating prior infection. Real-world risk factor-based screening in those with ≥1 CDC risk factor would have only identified 3/5 seropositive patients. In those screened, risk factor-based screening had sensitivity 60%, specificity 38.8%, PPV 2.8%, NPV 97.1%. There were no reactivations.
Proportion of patients with complete hepatitis b triple-screening at initiation of gynecologic chemotherapy (P-Chart)
Proportion of gynecologic chemotherapy prescribers ordering HBV screening with chemotherapy initiation (Run Chart)
Conclusion Implementation of four interventions to increase HBV screening in gynecologic oncology chemotherapy patients significantly improved screening rates, achieving our target at 9 months with sustained improvement. Risk factor-based screening lacks sensitivity compared to universal screening which impacts management.