Background/Purpose: Vaccination rates among patients with rheumatoid arthritis (RA) remain low.  Improving these rates is important, as RA patients are inherently immunocompromised and frequently treated with immunosuppressives.  To address this, we implemented a multifaceted, system-level intervention to improve pneumococcal (PVX) and zoster (ZVX)vaccination rates among patients with RA that was designed to make clinicians aware of their low vaccination rates, improve processes at the point of care (i.e., during a visit), and use panel-management strategies to contact patients between visits.

Methods:  This study was conducted at an academic medical center in Chicago, IL.  The study cohort included all adults seen in the faculty practice plan’s rheumatology clinic with a diagnosis of RA.  Our intervention had 3 main components: (1) clinicians received quarterly performance reports of the PVX and ZVX rates for their RA patients, generated from EHR data; (2) EHR clinical decision support best practice alerts (BPAs), designed to alert clinicians and facilitate PVX and ZVX administration at the point of care, and; (3) outreach to patients needing vaccination via mail or secure electronic messaging through the EHR patient portal, regardless of whether they had in-person clinic visits.  Study BPAs allowed clinicians to either link to a standing order set for vaccination at the time of the visit, document why vaccination was inappropriate, or write a prescription for the patient to receive ZVX elsewhere.  We assessed vaccination rates monthly from baseline in October 2013 through May 2014 using EHR data. For this interim analysis we assessed the statistical significance of differences in vaccination rates pre- and post-intervention.

Results: The study cohort included 1255 eligible patients. At baseline 293 (23.3%) had received PVX, and this increased to 524 (41.8%) at follow-up (p<0.001). An additional 11 (0.9%) patients had a documented medical exception for why PVX was not administered, and 53 (4.2%) had a documented refusal.  At baseline, 35 (2.8%) patients had received ZVX, and at follow-up 63 (5.0%) patients had received ZVX at clinic or received a prescription to receive ZVX elsewhere (p<0.01). During follow-up, 99 (7.9%) patients had a documented medical exception and 44 (3.5%) had a documented patient exception (refusal or financial barrier) for ZVX.

Conclusion:   Vaccination rates increased substantially following implementation of this multifaceted intervention.  However, the rate of PVX remained much lower than rates we have achieved for PVX using similar interventions in a primary care clinic, and ZVX rates remained quite low. The reasons for these suboptimal vaccination rates are unclear, but could be due to rheumatologists’ limited time to discuss prevention with patients or beliefs that vaccination is the responsibility of primary care providers.  Alternatively, our results could be due to clinical confusion following the recent publication of new PVX recommendations, and uncertainty regarding ZVX administration in immunocompromised patients under age 60.  Future research should seek to identify and overcome barriers to vaccination in this patient population.

---

« Back to 2014 ACR/ARHP Annual Meeting

ACR Meeting Abstracts - https://acrabstracts.org/abstract/leveraging-electronic-health-records-to-improve-vaccination-rates-for-patients-with-rheumatoid-arthritis/