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Coccidioides Serologic Screening Practices in Individuals With Rheumatic and Autoimmune Diseases
Debbie L Wilson1, Shubha Kollampare2, C Kent Kwoh3
1University of Florida, Gainesville.
Objective:
We aimed to estimate Coccidioides serologic screening rates before initiation of biologic disease-modifying antirheumatic drugs including tofacitinib (b/tsDMARDs), conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), and/or noninhaled corticosteroids.
Methods:
This retrospective cohort study used 2011 to 2016 US Medicare claims data and included beneficiaries with rheumatic or autoimmune disease residing in regions within Arizona, California, and Texas endemic for Coccidioides spp. with ≥1 prescription for a b/tsDMARD, csDMARD, and/or noninhaled corticosteroid. We estimated prior-year serologic screening incidence before initiating b/tsDMARDs, csDMARD, and/or noninhaled corticosteroid.
Results:
During 2012 to 2016, 4,331 beneficiaries filled 64,049 prescriptions for b/tsDMARDs, csDMARDs, and noninhaled corticosteroids. Arizona's estimated screening rate was 20.1% (95% confidence interval [95% CI] 14.5-25.7) in the year before prescription initiation for b/tsDMARDs, 8.1% (95% CI 6.5-9.7) before csDMARDs, and 6.9% (95% CI: 5.6-8.2) before corticosteroids. Screening rates for b/tsDMARDs (2.8%, 95% CI 0.0-6.7), csDMARDs (1.0%, 95% CI 0.0-2.0), and corticosteroids (0.8%, 95% CI: 0.4-1.1) were negligible in California and undetected in Texas. Adjusted screening rate before prescription for b/tsDMARDs in Arizona increased from 14.5% (95% CI 7.5-21.5) in 2012 to 26.7% (95% CI 17.6-35.8) in 2016. Rheumatologists prescribing b/tsDMARDs in Arizona screened more than other providers (20.9% [95% CI 13.9-27.9] vs 12.9% [95% CI 5.9-20.0]).
Conclusion:
Coccidioides serologic screening rates among Medicare beneficiaries with rheumatic/autoimmune diseases on b/tsDMARDs, csDMARDs, and noninhaled corticosteroids was low in Coccidioides spp.-US endemic regions between 2012 and 2016. Alignment of screening recommendations and clinical practice is needed.
Insights
Coccidioides screening rates were low for Medicare patients starting immunosuppressants in endemic areas. Improved adherence to screening guidelines is needed for patients on biologic disease-modifying antirheumatic drugs (b/tsDMARDs).
Area of Science:
- Rheumatology
- Infectious Diseases
- Public Health
Background:
- Coccidioides spp. infections pose a risk to immunocompromised patients.
- Biologic disease-modifying antirheumatic drugs (b/tsDMARDs), conventional synthetic disease-modifying antirheumatic drugs (csDMARDs), and corticosteroids increase infection risk.
- Pre-treatment screening for Coccidioides is recommended in endemic areas.
Purpose of the Study:
- To estimate Coccidioides serologic screening rates before initiating b/tsDMARDs, csDMARDs, and/or noninhaled corticosteroids.
- To assess screening practices among Medicare beneficiaries in Coccidioides-endemic regions of the US.
Main Methods:
- Retrospective cohort study using 2011-2016 US Medicare claims data.
- Included beneficiaries with rheumatic/autoimmune diseases in Arizona, California, and Texas.
- Estimated prior-year serologic screening incidence before initiating b/tsDMARDs, csDMARDs, or noninhaled corticosteroids.
Main Results:
- In Arizona (2012-2016), screening rates were 20.1% before b/tsDMARDs, 8.1% before csDMARDs, and 6.9% before corticosteroids.
- Screening rates were significantly lower in California (e.g., 2.8% for b/tsDMARDs) and undetected in Texas.
- Adjusted screening rates for b/tsDMARDs in Arizona increased from 14.5% in 2012 to 26.7% in 2016.
Conclusions:
- Coccidioides serologic screening rates were low among Medicare beneficiaries on immunosuppressants in endemic regions (2012-2016).
- Significant geographic disparities in screening rates were observed.
- Alignment between screening recommendations and clinical practice is necessary.
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