A Multifaceted Intervention to Improve Influenza, Pneumococcal, and Herpes Zoster Vaccination among Patients with Rheumatoid Arthritis

Abstract

Objective Vaccination rates for influenza, pneumococcus, and zoster in rheumatoid arthritis patients have remained low. Simple electronic or paper reminders have produced only small increases in vaccination rates. We sought to identify a more effective approach to improve vaccination rates. Methods We conducted a system-level intervention at an academic rheumatology clinic that included electronic reminders with linked order sets, physician auditing and feedback, patient outreach, and optional printed prescriptions for zoster vaccination at an outside pharmacy. Results We targeted 1255 eligible patients with rheumatoid arthritis. There was no change in patients’ self-reported influenza vaccination rates, although the baseline self-reported rate was already high and much higher than that documented in the electronic health record. Pneumococcal vaccination rates increased from 28.7% to 45.8%; in regression analysis, the rate of change in pneumococcal vaccination increased by 9.4% per year above baseline trends (95% CI = 3.9% - 15.5%; p = 0.002). The rate of zoster vaccination increased from 2.5% to 4.5% (p = 0.01) overall and from 3.0% to 6.6% among patients not receiving biologic therapy that preclude zoster vaccination. Conclusion Although the intervention improved pneumococcal and zoster vaccination rates, the improvement in pneumococcal vaccination rate was less than expected, and the zoster vaccination rate remained low even for ideal candidates. Likely barriers include lack of familiarity and difficulty using electronic reminders and order sets, uncertainty about the value and safety of recommended vaccines, and uncertainty about patients’ insurance coverage and prior vaccination history. Future interventions should include strategies to address these.

Interventions to improve vaccine acceptance among rheumatoid arthritis patients: a systematic review

“…The identified objective of the intervention was “improving vaccination rates” (in patients) [ 21 – 24 ], “reducing the frequency of any missed opportunities for vaccination” (in providers) [ 25 ], and “increase the documentation of prescriptions (in providers)” [ 21 , 24 ]. Three studies reported follow-up periods [ 22 , 23 , 25 ]. Time to post-intervention evaluations was generally 1 year, with two studies assessing patient vaccination rates monthly, for a median follow-up period of 12 [ 23 ] to 16 months [ 22 ].…”

“…Three studies reported follow-up periods [ 22 , 23 , 25 ]. Time to post-intervention evaluations was generally 1 year, with two studies assessing patient vaccination rates monthly, for a median follow-up period of 12 [ 23 ] to 16 months [ 22 ].…”

“…All studies included interventions that targeted provider behavior to increase vaccination rates, and all provider interventions involved some form of vaccination reminder to discuss or prescribe vaccination as the primary intervention, including Electronic Health Record (EHR) or Electronic Medical Record (EMR) alerts and Point-of-care paper reminder forms. Only three studies also targeted patients and included education [ 24 ] or letters/e-mail reminders [ 23 , 25 ] to improve vaccination rates. Intervention components varied considerably between studies.…”

“…Among provider-targeted interventions, we identified a total of three BCTs used across the two studies and included: (1) adding objects to the environment (i.e., paper reminder forms, 1/2 studies) [ 22 ], (2) monitoring behavioral outcomes (EHR best practice alerts, 1/2 studies) [ 21 ], and (3) pharmacological support (provided vaccination documentation or advice to get vaccinated, 2/2 studies) [ 21 , 22 ]. Among patient-targeted interventions, we identified a total of five BCTs including (1) adding objects to the environment (i.e., paper reminder forms, 2/3 studies) [ 23 , 25 ], (2) providing feedback on behavior (i.e., performance feedback, 2/3 studies) [ 23 , 24 ], (3) monitoring behavioral outcomes (EMR-based alert, 2/3 studies) [ 24 , 25 ], (4) instruction on how to perform the behavior (educational session (s) with follow-up assessments; 2/3 studies) [ 24 , 25 ], and (5) pharmacological support (provided vaccination documentation or advice to get vaccinated, 3/3 studies) [ 23 – 25 ] (see Table 2 ).…”

Development of a Canadian Core Clinical Dataset to Support High-quality Care for Canadian Patients with Rheumatoid Arthritis

“…EMR are becoming increasingly common in Canada 6 , with 70% of rheumatologists using an EMR system. EMR may be used to improve point-of-care monitoring and decision making 7,8 , for quality monitoring 1,9,10,11 , and for research purposes 12,13,14 . The standardization of data elements collected during routine rheumatology visits could, therefore, be important not only for supporting best practices and high-quality RA care, but also for supporting rheumatology research efforts.…”