People with rheumatoid arthritis (RA) are at increased risk for infection because of inherent immune dysregulation and chronic immunomodulatory therapy. However, uptake of the influenza vaccine (IVX), pneumococcal vaccine (PVX), and herpes zoster vaccine (HZVX) has been suboptimal among this at-risk group.
Researchers who conducted a single-center study found that a concerted effort to mount a system-level intervention made only modest inroads in improving vaccination rates. This disappointing result was attributed in part to flawed interoperability of electronic health records (EHRs), a widespread complaint throughout the US healthcare system; the need to identify a point person within a medical practice who is responsible for vaccination reminders and alerts; and the need for improved education of rheumatologists and other healthcare providers about the safety and efficacy of these vaccines, and what the current vaccine recommendations are for patients with RA.
“We conducted our study to implement and test a system-level intervention that included multiple quality improvement strategies to improve adherence to PVX, annual IVX, and HZVX among patients with RA, including electronic reminders with linked order sets, audit, and feedback to rheumatologists about their vaccination rates and how they compare to their peers, and outreach to patients,” David W. Baker, MD, MPH, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, and colleagues explained.
The study involved a 12-month, system-level intervention that targeted 1255 eligible patients with RA receiving care at the Northwestern Medical Group, an academic multispecialty practice staffed by faculty from the Feinberg School of Medicine at Northwestern University in Chicago, IL. More than 80% were women, mean age was 56 years, and 50.4% were white. Almost all patients had commercial insurance; 57.8% had commercial insurance, and 37.3% had Medicare or Medicaid. Sixty percent were currently being treated with a biologic, and 38.1% had ≥1 comorbidities.
Following the intervention, there was no change in patients’ self-reported IVX rates; however, the baseline rate was already high, and much higher than what was documented in the EHR.
Preintervention, 90.2% of patients had received IVX, and postintervention, 86.1% received IVX. Both pre- and postintervention, 80% of participants said they received IVX in the previous season. Prior to the intervention, 28.7% of patients received PVX, compared with 45.8% postintervention. A regression analysis found that the rate of PVX uptake increased annually by 9.4% compared with baseline (P = .002). The rate of HZVX uptake increased from 2.5% to 4.5% overall (P = .01), and from 3.0% to 6.6% among patients not treated with a biologic therapy that precludes HZVX.
“Although the intervention improved pneumococcal and zoster vaccination rates, the improvement in pneumococcal vaccination rate was less than expected, and the zoster vaccination remained low even for ideal candidates,” asserted the researchers.
According to the study authors, future interventions should address the obstacles they cited, including difficulty using EHR reminders and order sets, uncertainty on the part of doctors about the value and safety of recommended vaccines, and issues related to insurance coverage and prior vaccination history.
- Baker DW, Brown T, Lee JY, et al. A multifaceted intervention to improve influenza, pneumococcal, and herpes zoster vaccination among patients with rheumatoid arthritis. J Rheumatol. 2016 Apr 15. Epub ahead of print.