Although the risk for infection is twice as high in patients with autoimmune rheumatic arthritis (RA) compared with age- and gender-matched controls, vaccination rates among this patient population are consistently low, according to Diana S. Sandler, MD, Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, IL.
Evaluating Vaccination Behaviors
In an effort to better understand vaccination behavior of patients with RA and improve vaccination rates, Dr Sandler and colleagues conducted a telephone-based patient survey to examine the self-reported vaccination status of patients with RA. They also compared the participants’ vaccination statuses with the data in electronic health records (EHRs) at their institution, Northwestern Memorial Medical Center in Chicago, IL.
More than 1000 patients with RA met the study criteria for inclusion, including patients aged ≥18 years and ≥1 rheumatology clinic visits in the 2 years prior. The investigators performed manual chart reviews on selected proportions of patients and ceased patient recruitment after performing 100 interviews.
Between July 2013 and September 2013, potential respondents were called ≤6 times for participation in a 10-minute telephone survey. The survey comprised items from the Behavioral Risk Factor Surveillance System survey, as well as other items identified by the investigators, including receipt of influenza (INFVX), pneumococcal (PNVX), and herpes zoster (HZVX) vaccinations; attitudes about these vaccines (eg, reasons for not getting them); and provider recommendations for these vaccines.
Following the interviewer’s attempts to reach them, a total of 102 patients eventually completed the survey.
Self-Reported Vaccination Rates Low, Suboptimal
Although vaccination rates for influenza during the previous season was high (79.4%), Dr Sandler and colleagues found that vaccination rates for any previous PNVX vaccination was moderate (53.9%), and any previous HZVX vaccination was very low (7.8%). “If we assume that all self-reports are accurate and we include vaccinations recorded in the EHR that were not reported by patients, the vaccination rates were approximately 8% to 9% higher for PNVX and HZVX,” the study authors noted.
In response to, “How important do you think it is to get vaccinations to prevent infections?” 16.3% of respondents said it was somewhat important, 65.3% said it was very important, and 15.3% thought vaccines were of no importance at all. Seventeen of the 18 patients who reported feeling that vaccines were not important were taking immunosuppressive medications at the time of the study. Reasons for not being vaccinated varied with vaccine type. For PNVX and HZVX vaccines, the patients who had not received them said the vaccines had never been recommended to them. It was also more common for patients to dislike or distrust INFVX vaccinations versus PNVX or HZVX vaccines.
Although three-fourths of respondents reported that a physician had informed them of their increased risk for infection, only 64% could actually remember being told about the significance of vaccines by their providers.
“The reasons why physicians fail to recommend vaccinations for immunocompromised patients are not fully understood,” the study authors noted. In particular, they added that it is possible that this gap in care can be due to patients consulting a rheumatologist and a primary care physician. Rheumatologists may assume that as part of preventive care, it is the responsibility of the primary care provider to discuss vaccinations. However, primary care providers may not be knowledgeable about guidelines for vaccinations in immunosuppressed patients or feel that it is the responsibility of the rheumatologist.
Because patients with RA are at increased risk for infection, vaccinations are a vital part of their care. The study authors asserted that numerous steps including clarifying recommendations from national organizations, providing better education to patients about their risks for infection and need for vaccines, and team-based care for identifying patients who need vaccines are ways to improving vaccination rates.
“In any situation, such as in patients with chronic pulmonary disease, where maximizing vaccination rates is an important element of care, there are important lessons to be gleaned from this study about the role of identifying and delineating responsibilities in team-based care,” stated Dr Sandler and colleagues. “The increasing use of EHRs, including patient portals for secure electronic communication, should facilitate implementation of multifaceted interventions to improve vaccination rates.”
The authors concluded that further investigations into barriers to vaccination, as well as the impact of evidence-based, provider-level interventions on vaccination rates, are required.
- Doran MF, Crowson CS, Pond GR, et al. Frequency of infection in patients with rheumatoid arthritis compared with controls: a population-based study. Arthritis Rheum. 2002;46:2287-2293.