Background/Purpose: Reactivation of the varicella zoster virus (shingles) creates a significant burden of healthcare dollars, lost work time, and extended suffering. Rheumatoid Arthritis (RA) and its treatments increase the risk of shingles 2-3x that of the general population. Despite the higher rate of reactivation and potential cost to healthcare, only about 5% of RA patients receive the zoster vaccine. Currently, the ACR recommends zoster vaccination for patients over age 60 on non-biologic DMARDs or prior to starting biologic therapy.  We aimed to measure the size of our unvaccinated RA population, understand the barriers to vaccination, and develop a plan to increase shingles vaccination.

Methods: We gathered data on our RA patients over age 60 on Disease Modifying Antirheumatic (DMARD) therapy who have ever had shingles or the shingles vaccine prior to 5/29/15 using ICD-9 codes from the EPIC electronic health record. To establish why patients were un-vaccinated we surveyed RA patients at their routine clinic visits over 3 weeks. Patients were permitted to choose more than one answer. Demographics were recorded and survey results were tallied.  System-wide baseline data on shingles diagnosis and vaccination rate was compared to that of our surveyed population.

Results: We surveyed 107 patients. 38 were excluded due to missing demographics, incorrectly completed surveys, not on DMARD, or < 50 years old (36%). 69 patient surveys were included for a total of 75 responses. System-wide, 211 out of 2259 RA patients on DMARD had a history of shingles (9.3%) compared to our survey group, where 5 out of 72 had a history of shingles (6.9%).  System-wide, 184 out of 2259 received the vaccine (8.1%) compared to our survey group where 10 out of 72 (13.8%) received the vaccine. Of the patients who had a shingles diagnosis, 78 (40%) were on a DMARD at the time of diagnosis.  Results of the survey are listed in the table below:

Conclusion: Our health system’s zoster vaccine rate for RA patients was slightly above the national average but still leaves a considerable care gap. Since the largest unvaccinated population was started on a biologic prior to vaccination our biggest opportunity to close this care gap exists before patients start biologic. We believe a process change to integrate the zoster vaccine into pre-biologic initiation workflow would increase the vaccination rate.  This coupled with a real time point-of-service quality measure tool actionable by the nurse and provider would provide timely feedback.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/zoster-vaccination-in-rheumatoid-arthritis-patients-an-unmet-care-gap/