Background/Purpose:

American College of Rheumatology (ACR) guidelines recommends the administration of killed vaccines [pneumococcal, influenza and hepatitis B (HepB)], recombinant human papillomavirus (HPV) vaccine and live attenuated herpes zoster (HZV) vaccinations prior to therapy with DMARDs or biologic agents. HepB vaccination is indicated if hepatitis risk factors are present. Rheumatoid arthritis (RA) patients already on a DMARD or a biologic agent, vaccination with pneumococcal, influenza, HepB and HPV vaccine should be administered as indicated. RA patients already on a DMARD (non biologics) may be vaccinated with HZV vaccine.

Objective:

The question addressed in this quality improvement project was to ascertain whether veterans with RA at our VA Medical Center (VAMC), are being vaccinated as per ACR guidelines.

Methods:

A retrospective chart review was performed. Patients were identified using clinic encounters with an associated ICD9 code for RA (714.0, 714.2) in the Computerized Patient Record System (CPRS) at our VAMC, from January 1, 2011 through April 23, 2013. Charts were searched using several keywords, for documentation of these vaccinations, either offered or received.

Results:

A total of 330 RA patients were identified, of which 251 were included. Out of the 79 patients excluded, 59 did not have a definitive diagnosis of RA and 20 had insufficient records. The mean age was 74 years, 92% males and 88% Caucasian. Among the included patients 54.5% had been treated with methotrexate, 35.8%  hydroxychloroquine, 65% corticosteroids, 15% sulfazalazine, 6.7% leflunamide, 1.6% azathioprine and 38.6% with a biologic agent. Out of the patients who had been on a DMARD or biologic agent, 95.6% were either offered or received influenza vaccine, 93% pneumococcal vaccine, and 20.5% HZV vaccine. In addition, 1.5% had received Hep B vaccine. HPV vaccine was not indicated as per the vaccination guidelines due to age limitations. In a subset analysis, 53.4% of the patients either received or were offered influenza vaccine in each of the last three years (2010, 2011, 2012), 24% patients in two of the last three years, 17.5% patients only once and the remaining 5.1% were not offered the vaccine.

Conclusion:

At our center, documented pneumococcal vaccination rates were high but annual influenza and HZV vaccination rates were suboptimal.   

The low HZV vaccination rate could be due to some patients already on biologic agents prior to the vaccine approval in 2006 and initial difficulties in obtaining the vaccine. Annual influenza vaccination rates were less than desired. This could be due to missed annual follow ups, unavailable documentation of vaccination administered outside the VAMC & patients who had expired. HepB vaccination rate was also low; however, analysis regarding the presence of hepatitis risk factors was not performed.

Limitations of our analysis were unavailability of vaccination data prior to 1999 before CPRS was implemented and difficulty in obtaining data from outside the VA.

Better adherence to vaccination guidelines and documentation is required. This may be achieved through interventions such as physician and nursing staff education, and use of clinical reminders in CPRS.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/determining-the-vaccination-rates-of-american-college-of-rheumatology-recommended-vaccines-among-veterans-with-rheumatoid-arthritis-a-quality-indicator/