Increasing Pneumococcal Vaccination for Immunosuppressed Patients:

A Cluster Quality Improvement Trial

Background/Purpose:   It is important for patients on immunosuppressive medications to receive pneumococcal vaccination. Prior studies suggest that most patients do not undergo vaccination. We evaluated the effects of a point-of-care paper reminder form on being up-to-date with pneumococcal vaccination in a rheumatology practice.

Methods: Selected rheumatologists at five ambulatory practice sites received a point-of-care paper reminder form for patients who were not up-to-date with pneumococcal vaccination. Interrupted time-series analyses were used to measure the effect of the paper reminder form upon the intervention rheumatologists compared to the control rheumatologists.  Adjusted Cox proportional hazards models were examined to identify independent predictors of being up-to-date with pneumococcal vaccination.

Results: We evaluated a total of 3,717 patients on immunosuppressive medications. In this group 66.0% had rheumatoid arthritis:74.1% were female, and the mean age was 53.7 years. Rheumatologists who received the intervention had a significant increase in the rate of patients up-to-date with pneumococcal vaccination from 67.6% to 80.0% in the time period following the intervention (p=0.006), whereas rheumatologists in the control group had stable rate from 52.3% to 52.0% (p=0.90). In regression models, the intervention [hazard ratio, HR=3.58, (95% CI 2.46-5.20)], having a primary care physician affiliated with our hospital [HR=1.68, (95% CI 1.44-1.97)], and having a diagnosis of diabetes mellitus [HR =1.57, (95% CI 1.02-2.41)] were positive predictors of being up-to-date with vaccination.

Conclusion:  A simple point-of-care paper reminder for patients on immunosuppressive medications significantly increased the rate of being up-to-date with pneumococcal vaccination among intervention rheumatologists over a six-month period.

Figure 1. Pneumococcal vaccination over time, before and after point-of-care reminder intervention 

Figure 1 shows the percentage of patients up-to-date with pneumococcal vaccination over time. The intervention was applied in two waves, with ten physicians receiving the intervention in June 2010 and four additional physicians receiving the intervention in October 2010. In order to synchronize these data, time 0 was defined as the time that the intervention was applied to the patients of the treating rheumatologist. The red line represents the 21 rheumatologists in the control group and the blue line represents the 14 rheumatologists in the intervention group.