Leveraging Social Risk Factor Screening Infrastructure in Rheumatology Clinics to Respond to Rising Rates of...

Immunocompromised individuals with rheumatic conditions have heightened risk of tuberculosis (TB) infection, reactivation, and severe disease. Patients with social risks are especially vulnerable. After an alert of increased TB rates among individuals experiencing homelessness in Massachusetts, we leveraged the existing social risk screening infrastructure to identify those at highest risk.

We identified patients with rheumatic conditions receiving immunosuppressive or immunomodulatory medications and recent housing instability from the electronic health records (EHRs) of a multihospital medical system. We notified these patients' rheumatologists and provided latent TB and TB symptom screening information. We tracked EHR documentation, orders, and laboratory results following this alert.

Thirty-three patients with rheumatic conditions experienced housing instability. Of these, 23 (70%) patients cared for by 17 rheumatologists were prescribed ≥1 immunosuppressive or immunomodulatory medications. Following the alert, three (13%) patients had EHR documentation of symptom screening, one provider responded that their patient was not homeless, and one ordered an interferon-gamma release assay ("T-SPOT"). After the reminder, seven (30%) T-SPOT tests were ordered, five (22%) patients had EHR documentation of symptom review at their subsequent rheumatology appointment, and four (18%) patients were messaged by their rheumatologists about their TB risk.

The existing rheumatology-based social risk factor screening infrastructure facilitated a rapid response to a relevant public health concern. Rheumatologists' responses varied, possibly due to increased clinical stressors with limited support. Despite challenges to reaching patients with housing instability, many actions were taken. Efforts to prompt regular TB screening of patients with these vulnerabilities are underway.