Workflow-embedded automation improves hepatitis B screening and safety in b/tsDMARD users

Despite guideline-mandated universal screening, adherence to hepatitis B virus (HBV) testing before the initiation of biological or targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) remains suboptimal, placing patients at risk for HBV reactivation (HBVr).

We retrospectively studied 1,909 adults starting b/tsDMARD therapy from 2004 to 2024, comparing three stages: baseline (2004-2016), education (2017-2020), and work-flow-integrated (2021-2024). In the last stage, a workflow-embedded clinical decision support system (CDSS) was integrated into computerized order entry to automatically verify HBV serologic status and generate missing screening orders at the point of prescription. The outcomes assessed were pre-treatment HBV screening completion, monitoring frequency, and HBVr-related clinical events.

HBV screening rates progressively improved across stages. HBsAg testing increased from 91% at baseline to 98% during the workflow integrated stage. Completion of the two-marker panel (HBsAg/anti-HBc) increased from 63% to 93%, whereas full three-marker panel testing increased from 47% to 90%. These process improvements were accompanied by a significant reduction in HBVr, which decreased from 5.2% to 1.5% (p < 0.001), and hepatitis flares, which decreased from 1.9% to 0.2% (p < 0.001). However, antiviral prophylaxis before b/tsDMARD initiation remains uncommon (4.2%) and HBV DNA monitoring is infrequently performed.

Workflow-embedded CDSS led to almost universal HBV screening and notable reductions in HBV reactivation and flares. The remaining risk suggests that future systems should include automated long-term monitoring and better enforcement of prophylactic guidelines.