From the 2019 HVPAA National Conference
Dr. Soorya Aggarwal (Lehigh Valley Health Network), Dr. Kyle Kreitman (Lehigh Valley Health Network), Dr. Andrea Soliman (Lehigh Valley Health Network), Dr. Kourtney Erickson (Lehigh Valley Health Network), Dr. Abdul Aleem (Lehigh Valley Health Network), Dr. Marie O’Brien (Lehigh Valley Health Network)
Background
Biologic or immunosuppressive agents have changed the course of chronic debilitating autoimmune conditions. Despite their advantages, these agents come with risk of vaccine preventable infections.1 Multiple national organizations recommend scheduled influenza and pneumococcal vaccinations in all patients on chronic immunosuppressives.2,3
Clarity regarding indication and timing of vaccinations has been problematic as new biologic therapies enter clinical practice. A 1996 Medicare survey of 16,000 patients showed a common reason for low adherence among patients on biologics is not knowing the indications or schedules for vaccinations.5 While physician specialists often initiate biologic therapy, primary care physicians typically have more access to vaccines. As a result, according to the Center for Disease Control (CDC) in 2014, vaccination adherence remains low amongst high-risk persons aged 19-64 years.4
Objective
In an outpatient primary care setting, we implemented an educational and protocolized vaccination program for patients on immunosuppressive medications to increase influenza and pneumococcal vaccination adherence by at least 15% for each vaccine.
Methods
A retrospective, chart analysis identified 756 patients on specific biologic agents in Internal Medicine and Rheumatology practices. From this population, each patient was evaluated for compliance with CDC guidelines for immunocompromised patients for Influenza, Pneumococcal 13-Valent Conjugate and Pneumococcal Polyvalent vaccines. After the data was collected, each practice in the study received educational outreach to improve vaccination adherence. They were also given resources to serve as reminders for vaccination schedules. After the completion of the subsequent influenza season, the same patients were reviewed to obtain adherence data after the intervention.
Results
Of the patients studied, a majority of patients (65.2%, n=493) had rheumatoid arthritis. The most common medications used were etanercept (35.5%, n=268) and adalimumab (35.1%, n=265). Prior to the educational program, 62.0% (n=469) were up to date on influenza vaccinations, 34.0% (n=257) were up to date on pneumococcal 13-valent conjugate and 51.9% (n=392) were up to date on pneumococcal 23 vaccination. After the program, 65.1% (n=487) were up to date on influenza, 49.9% were up to date on pneumococcal 13-valent conjugate and 59.8% (n=447) were up to date on the pneumococcal 23 vaccine. Overall, adherence to vaccination schedule increased from 18.9% (n=143) to 29.9% (n=224).
Conclusion
Patients on biologic therapies remain vulnerable to vaccine preventable illnesses such as Pneumococcal Pneumonia and Influenza. In general, the education program for clinicians was well received and did increase adherence to vaccination schedules for these three common vaccines. Despite this, inadequate resources and communication issues still remained an obstacle for primary care providers and specialists. Based on feedback from clinicians, a vaccination clinic is already being developed in order to improve access to patients requiring vaccinations. Additionally, we have been working to optimize our best practice alert advisory through EMR to improve communication between providers for our at risk population.
Clinical Implications
Based on our quality improvement initiative, there was an increase in vaccination adherence in an at risk patient population. Through educational outreach, we were able to increase awareness of vaccination adherence in patients on biologic medications. Based on our project, a vaccination clinic is being developed to increase access to resources and we are optimizing EMR tools to improve communication between providers.
