Gaps in Care for Hydroxychloroquine-Related Retinopathy Screening in British Columbia: A Population-Based Cohort Study

Objectives To describe rates of adherence to current guidelines for hydroxychloroquine-related retinopathy (HCQ-R) screenings among long-term (≥1 year) HCQ-users in British Columbia (BC) and to identify associated healthcare-system and patient-level predictors.[1] Methods We conducted a longitudinal retrospective-cohort (Jan 1, 1997-Dec 31, 2023) using BC administrative health data (capturing all provincially funded services including outpatient and hospital visits, dispensed medications, and demographics). We identified all adults with systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA) who started HCQ after diagnosis and remained on HCQ for ≥1 year. We followed this cohort for HCQ-R screening from HCQ initiation assessing for baseline and subsequent annual screenings until HCQ discontinuation, loss-to-follow-up, death or administrative end of study. Outcome: A valid screening (guideline-concordant): (1) ICD-9 code (362.XX or V67.51) by an ophthalmologist/optometrist and (2) an optical coherence tomography (OCT) (22067) or/and visual-field (02043) fee item billed by an ophthalmologist/optometrist. We defined “no screening” as the absence of both retinal-exam ICD9-code and OCT/visual-field fee-items. Statistical analyses: We estimated the rates of valid screening at baseline and annually among those remaining on HCQ (risk set). Multivariable generalized-estimating-equations assessed association of valid annual screening with predictors including physician-care pattern (continuous-rheumatologist-care (Rheum-care), family-physician-only-care (FP-only), intermittent rheumatologist-care with gaps of family-physician-only-care (Int-Rheum-FP-only) or started by rheumatologist-care then hands-off to family-physician-only-care (Start-Rheum-then-FP-only)), regional healthcare authority, baseline screening, years since HCQ initiation, demographics, and comorbidity. Results Among 22,572 HCQ initiators (75.26% female; mean age 53.64±15.06 years; SLE 8.52%; mean HCQ-exposure 6.40±5.34 years), only 4,400 (19.5%) had a valid baseline screening and 11,676 (51.7%) had no screening. From year 2 to 25, risk set decreased from 21,634 to 809 with valid annual screening ranged from 17.9% to 22.5%. Rates of no screening remained almost constant (~63%). Relative to Rheum-care, odds of having valid annual screening (adjusted-OR, 95% CI) were lower (P-value<0.0001) for FP-only (0.67, 0.62-0.72), Int-Rheum-FP-only (0.71, 0.68-0.75), and Start-Rheum-then-FP-only (0.64, 0.58-0.71). Compared to Vancouver-Coastal health, odds were lower (P-value<0.0001) in Interior (0.84, 0.79-0.90), Fraser (0.76, 0.71-0.81), Northern (0.71, 0.66-0.76), and Island (0.34, 0.31-0.39) health authorities. Table 1 presents adjusted-ORs for valid baseline screening, years since HCQ initiation, and patient-level predictors (Table 1). Table 1. Patient-Level Predictors Associated with Valid (Guideline-Concordant) Annual HCQ-related Retinopathy (HCQ-R) Screening Conclusion In this real-world longitudinal study, about 50% of HCQ initiators and 63% of long-term HCQ users did not receive guideline-concordant HCQ-R screenings. Baseline screening and continuous rheumatologist care had strong association with ongoing guideline-concordant annual screenings. Strengthening guideline-oriented practices and addressing regional gaps may improve screening and reduce preventable vision loss. References [1.] Marmor MF. Ophthalmology 2016;123:1386-94.