Background/Purpose:

Patients with Systemic Lupus Erythematosus (SLE) lupus are up to 13 times more likely to develop invasive pneumococcal infections, resulting in increased morbidity and mortality. Vaccination against S. pneumoniae is therefore recommended in all patients with SLE, however, vaccination rates in routine rheumatology care remain low. Barriers to vaccination are lack of provider recommendation, concerns about vaccine efficacy and safety, lack of vaccine supply, incomplete immunization records and time. The aim of this study was to increase pneumococcal vaccination rates in patients with Childhood-onset SLE (c-SLE) from 3.6% to 50% in 1 year and 80% by the following year. This report describes the interim results at 9-months from the initiation of the project.

Methods:

Patients with childhood-onset SLE followed in the pediatric rheumatology clinic at Nationwide Children’s Hospital from 1/1/2015 to 8/31/2016 were included for the baseline analysis. Newly diagnosed patients with c-SLE were included for the ongoing study. A letter was sent to these patients and their primary care providers requesting an updated immunization record. An age-based algorithm was developed for pneumococcal conjugate (PCV13) and pneumococcal polysaccharide (PPSV23) vaccination based on current ACIP guidelines, followed by an education session for rheumatology providers and clinic staff. Pre-visit planning included: 1) Generating a weekly report of upcoming appointments for c-SLE patients, 2) Entering updated immunization records with the help of the clinical pharmacist in the electronic health record (EHR), identifying candidates for vaccination, and notifying the rheumatology team of vaccination opportunities on a weekly basis, and 3) Weekly monitoring by clinic nurses to ensure adequate vaccine stock.

Results:

83 patients with c-SLE were seen in the pediatric rheumatology clinic in the baseline period, with a median age of 18.3 years (range 7-24). An additional 8 newly diagnosed patients were included in this analysis, with a total of 91 patients. Over the study period, the number of patients with updated vaccine records in the EHR increased from 25.6% to 65.1%. Vaccination rates for PCV13 increased from 8.4% to 49.4% (p<0.0001) and PPSV-23 rates increased from 24.1% to 32.9%. A total of 20/91 (21.9%) were appropriately immunized with both vaccines, compared with 3.6% at baseline (p<0.0001). Notably, 60.4% of patients had received at least 1 dose of pneumococcal vaccine as compared to 28.9% at the start of the study (p<0.0001).

Conclusion:

This study highlights the benefits of pre-visit planning in improving pneumococcal vaccination in patients with c-SLE. Access to updated immunization records in the EHR at the time of the visit facilitated timely decision making. Targeted vaccine recommendations prior to the visit minimized the time burden on providers and served as a reminder to order the vaccine. Future efforts will be directed at building clinical decision support in the EHR for vaccinations in high-risk individuals, evaluating vaccine immunogenicity and expanding the service to patients with other pediatric rheumatic diseases.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/pre-visit-planning-improves-pneumococcal-vaccination-in-patients-with-childhood-onset-systemic-lupus-erythematosus/