Improved influenza and pneumococcal vaccination in rheumatology patients taking immunosuppressants using an electronic health record best practice alert

Vaccination of Adults With Cancer: ASCO Guideline

PURPOSE

To guide the vaccination of adults with solid tumors or hematologic malignancies.

METHODS

A systematic literature review identified systematic reviews, randomized controlled trials (RCTs), and nonrandomized studies on the efficacy and safety of vaccines used by adults with cancer or their household contacts. This review builds on a 2013 guideline by the Infectious Disease Society of America. PubMed and the Cochrane Library were searched from January 1, 2013, to February 16, 2023. ASCO convened an Expert Panel to review the evidence and formulate recommendations.

RESULTS

A total of 102 publications were included in the systematic review: 24 systematic reviews, 14 RCTs, and 64 nonrandomized studies. The largest body of evidence addressed COVID-19 vaccines.

RECOMMENDATIONS

The goal of vaccination is to limit the severity of infection and prevent infection where feasible. Optimizing vaccination status should be considered a key element in the care of patients with cancer. This approach includes the documentation of vaccination status at the time of the first patient visit; timely provision of recommended vaccines; and appropriate revaccination after hematopoietic stem-cell transplantation, chimeric antigen receptor T-cell therapy, or B-cell-depleting therapy. Active interaction and coordination among healthcare providers, including primary care practitioners, pharmacists, and nursing team members, are needed. Vaccination of household contacts will enhance protection for patients with cancer. Some vaccination and revaccination plans for patients with cancer may be affected by the underlying immune status and the anticancer therapy received. As a result, vaccine strategies may differ from the vaccine recommendations for the general healthy adult population vaccine.Additional information is available at www.asco.org/supportive-care-guidelines.

Improving Pneumococcal Vaccination Rates in Immunosuppressed Pediatric Patients with Rheumatic Disease

Background

Patients with rheumatic diseases are at a high risk of invasive pneumococcal disease due to immunosuppression. We conducted a quality improvement project, and the first aim was to increase the percentage of patients with systemic lupus erythematosus and mixed connective tissue disease that is up to date on pneumococcal vaccinations from 9.6% to 80% within one year. Subsequently, the second aim was to increase the percentage of patients on immunosuppression with systemic lupus erythematosus, mixed connective tissue disease, juvenile dermatomyositis and systemic vasculitis that is up to date on pneumococcal vaccinations from 62.6% to 80% within one year.

Methods

Two process measures were up-to-date vaccination status on (1) 13-valent pneumococcal conjugated vaccine (PCV13) and (2) 23-valent pneumococcal polysaccharide vaccine (PPSV23). Our outcome measure was being fully up to date on both pneumococcal vaccinations. Interventions included an immunization algorithm, reporting of eligible patients, education, reminders, and pre-visit planning.

Results

There were shifts in the centerline for all quality measures in both phases of this project. The combined pneumococcal vaccination rate for Phase 1 increased from 9.6% to 91.1%, and this centerline was sustained. Pneumococcal vaccination rates also significantly increased for Phase 2: 68.8% to 93.4% for PCV13, 65.2% to 88.5% for PPSV23, and 62.6% to 86.5% for the combined pneumococcal vaccination rate.

Conclusions

Quality improvement methodology significantly increased and sustained pneumococcal vaccination rates in our high-risk, immunosuppressed patients. We continue to prioritize this important initiative to mitigate the risk of invasive pneumococcal disease.

Effect of a Best-Practice Alert on the Rate of Smoking Cessation among Pregnant Women

OBJECTIVE

 This study aimed to determine if a best-practice alert (BPA) implementation increases the rate of smoking cessation during pregnancy and affects pregnancy outcomes associated with smoking.

STUDY DESIGN

 This was a pretest-posttest study design where a BPA was added to electronic medical records (EMR) of pregnant persons who reported active smoking. The BPA provided the 5A's method to conduct counseling on smoking cessation. The rates of smoking cessation during pregnancy were compared 1.5 years before and after implementation of the BPA. Secondary outcomes examined whether counseling on smoking cessation was done, the number of the counseling sessions during pregnancy, and obstetric outcomes associated with maternal smoking.

RESULTS

 After implementation of the BPA, the rate of smoking cessation in pregnancy increased from 17.5% prior to BPA implementation to 54.9% after BPA implementation (p < 0.001). The rate of counseling on smoking cessation increased from 66.6% prior to BPA implementation to 95.6% after BPA implementation, with an increase noted also in the number of smoking cessation counseling sessions. In multivariate analyses, after controlling for maternal demographic and clinical factors, BPA implementation was significantly associated with higher rates of smoking cessation (adjusted odds ratio [aOR]: 3.44, 95% confidence interval [CI]: 2.17-5.51), higher rates of documented smoking cessation counseling in the EMR (aOR: 12.44, 95% CI: 6.06-25.64), and higher odds of conducting the counseling more than once (aOR: 6.90 95% CI: 4.45-10.88).

CONCLUSION

 The rate of smoking cessation and number of times pregnant persons were counseled increased after implementation of a BPA. The BPA could be a useful EMR tool to increase smoking cessation rates during pregnancy.

KEY POINTS

· Smoking during pregnancy is a maternal and fetal concern.. · Prenatal care offers the chance to address smoking.. · BPA increases rates of smoking counseling and cessation..

Interventions Increase Vaccination Rates in Inflammatory Bowel Disease and Rheumatoid Arthritis: A Systematic Review and Meta-Analysis

BACKGROUND

Patients with immune-mediated conditions such as IBD and RA are at risk for vaccine-preventable infections. Despite guideline recommendations, prior studies have shown suboptimal vaccination rates.

AIM

We conducted a systematic review and meta-analysis to compare the different interventions intended to increase vaccination rates.

METHODS

A systematic search was conducted of MEDLINE/PubMed, Embase, CINAHL, and Cochrane Library up to 2020 for studies with interventions intended to increase vaccination rates. We performed a random-effects meta-analysis to generate pooled odds ratios (ORs) to assess all interventions against no interventions. Our primary outcome was pneumococcal vaccination (PCV) rate.

RESULTS

Our review found 8580 articles, for which 15 IBD and 8 RA articles met the inclusion criteria; 21 articles were included in the analysis. PCV was the predominant vaccination (91%). In our analysis of patients with IBD, almost all interventions (patient-oriented, physician-oriented, or barrier-oriented) increased PCV uptake [OR, 4.74; 95% CI, 2.44-6.56, I2 = 90%] compared to no intervention. The greatest effect was seen in barrier-oriented studies [OR, 12.68; 95% CI, 2.21-72.62, I2 = 92%]. For RA data, all interventions had increased PCV uptake compared to no interventions (OR 2.74; 95% CI, 1.80-4.17, I2 = 95%).

CONCLUSION

Our data suggest that many different interventions can increase PCV rates. It appears that barrier-oriented interventions may have the greatest positive effect on increasing PCV uptake. However, clinicians should be encouraged to implement measures best suited to their practice. Future high-quality randomized controlled trials are needed to determine the best approach to optimize vaccination rates.

Vaccines in adults with autoimmune inflammatory rheumatic disease: What are the knowledge and attitudes of physicians?

Objectives

The aim of this study was to evaluate the knowledge and practices about vaccination in adults with autoimmune inflammatory rheumatic diseases (AIRD) among primary care physicians (PCPs), internal medicine specialists (IMSs), and rheumatologists and to emphasize the importance of vaccination.

Patients and methods

Between March 2021 and April 2021, a total of 310 IMSs, PCPs, and rheumatologists (132 males, 178 females; mean age: 37.4±9.5 years; range, 24 to 64 years) were included. A web-based questionnaire was used in the study.

Results

Of the physicians, 87.7% were aware of that patients with AIRD were among adults with vaccination indications, but 53.9% reported that they knew about recommended vaccines, and 53.2% recommended vaccines to their patients. The most common reasons for not recommending vaccination were reservations about the drugs used (22.3%) and lack of information (17.7%). Those with longer practice as physicians and older physicians had less knowledge about the vaccine than the other participants. While 59.7% of the participants thought that the vaccination plans of the patients should be made by the rheumatologist, the rate of PCPs who did not prefer to apply the planned vaccines in the first step was 50.7%. A total of 50% of the participants did not recommend the administration of the COVID-19 vaccine in a primary healthcare institution to those receiving immunosuppressive therapy.

Conclusion

Considering that one of the major obstacles to adult vaccination is the physician's refusal to recommend it, our study highlights the missing points in the vaccination knowledge and approach of physicians. Providing advice on adult vaccination and immunization of risky groups to more physicians and periodic training to prevent loss of knowledge after graduation may contribute to an increase in the vaccination rate of adults with AIRD.

Primary Care Professionals' Attitudes Towards Vaccination Recommendation for Patients With Inflammatory Bowel Disease

BACKGROUND

Immunization among patients with inflammatory bowel disease (IBD) is suboptimal. We sought to characterize attitudes of US primary care professionals (PCPs) towards immunization practices for patients with IBD.

METHODS

Using a web-based opt-in panel of PCPs (DocStyles survey, spring 2021, cross-sectional study), we assessed likelihood of PCPs' recommending influenza, pneumococcal disease, herpes zoster, and human papilloma virus vaccinations for IBD patients by PCP characteristics and availability of clinical tools. Reasons for unlikelihood of recommending vaccines and approaches to improve vaccine recommendation were examined.

RESULTS

Among 1503 PCPs, 64% recommended all vaccines. Herpes zoster vaccine was most likely to be recommended (89.8%) and pneumococcal vaccine was least likely (74.0%). Clinical tools including decision support based on electronic health records (EHRs; 48.9%) and staff tracking of patients' vaccine needs (36.3%) were significantly associated with likelihood of recommending vaccines (P < .001). A greater likelihood of vaccine recommendation was observed for pediatricians vs other medical specialties, group outpatient clinic vs other worksites, and seeing >50 patients/week (P < .05). One-third of PCPs were unlikely to recommend ≥1 vaccine, and the top reason reported was unfamiliarity with vaccine guidelines for patients with IBD (48.0%). A review of guidelines or continued medical education (63.0%) and decision support from EHRs (51.2%) were the most frequently selected approaches identified to improve certainty of vaccine recommendation.

CONCLUSIONS

There is room for improvement of vaccination recommendations by PCPs. Promoting continuing education and use of clinical tools may help support PCP immunization practices for patients with IBD.

Impact of an Automated Best Practice Alert on Sex and Race Disparities in Implantable Cardioverter-Defibrillator Therapy

Background

Implantable cardioverter‐defibrillators (ICDs) are indicated in patients with severe left ventricular dysfunction, but many eligible patients do not receive them, especially women and Black patients. Our group had previously demonstrated that a best practice alert (BPA) improves overall rates of electrophysiology referrals and ICD implantations. This study examined the impact of a BPA by sex and race.

Methods and Results

This is a cluster randomized trial of cardiology (n=106) and primary care (n=89) providers who were randomized to receive (BPA, n=93) or not receive (No BPA, n=102) the alert and managed 1856 patients meeting primary prevention criteria for ICD implantation (965 BPA and 891 No BPA). After a median follow up of 34 months, 630 (34%) patients were referred to electrophysiology, and 522 (28%) patients received an ICD. Compared with the No BPA arm, patients in the BPA arm saw a modest differential increase in the rate of electrophysiology referrals at 18 months in men (+4%) compared with women (+7%) but a profound increase in Black patients (+16%) compared with White patients (+2%), thus closing the sex and race gaps. Similar trends were noted for rates of ICD implantation.

Conclusions

Use of a BPA improves rates of electrophysiology referrals and ICD implantations in all comers with severe cardiomyopathy and no prior ventricular arrhythmias but has a more pronounced impact in women and Black patients. The use of a BPA at the point of care is an effective tool in the fight against sex and race inequities in health care.

SUPPORT-AF IV: Supporting use of AC through provider prompting about oral anticoagulation therapy for AF clinical trial study protocol

Background

Six million Americans suffer from atrial fibrillation (AF), a heart rhythm abnormality that significantly increases the risk of stroke. AF is responsible for 15% of ischemic strokes, which lead to permanent disability in 60% of cases and death in up to 20%. Anticoagulation (AC) is the mainstay for stroke prevention in patients with AF. Despite guidelines recommending AC for patients, up to half of eligible patients are not on AC. Clinical decision support tools in the electronic health record (EHR) can help bridge the disparity in AC prescription for patients with AF.

Objective

To enhance and assess the effectiveness of our previous rule-based alert on AC initiation and persistence in a diverse patient population from UMass-Memorial Medical Center and University of Florida at Jacksonville.

Methods/Results

Using the EHR, we will track AC initiation and persistence. We will interview both patients and providers to determine a measure of satisfaction with AC management. We will track digital crumbs to better understand the alert’s mechanism of effect and further add enhancements. These enhancements will be used to refine the alert and aid in developing an implementation toolkit to facilitate use of the alert at other health systems.

Conclusion

If the number of AC starts, the likelihood of persisting on AC, and the frequency alert use are found to be higher among intervention vs control providers, we believe such findings will confirm our hypothesis on the effectiveness of our alert.

Effect of Electronic Health Record Reminders for Routine Immunizations and Immunizations Needed for Chronic Medical Conditions

BACKGROUND

 Immunization reminders in electronic health records (EHR) provide clinical decision support (CDS) that can reduce missed immunization opportunities. Little is known about using CDS rules from a regional immunization information system (IIS) to power local EHR immunization reminders.

OBJECTIVE

 This study aimed to assess the impact of EHR reminders using regional IIS CDS-provided rules on receipt of immunizations in a low-income, urban population for both routine immunizations and those recommended for patients with chronic medical conditions (CMCs).

METHODS

 We built an EHR-based immunization reminder using the open-source resource used by the New York City IIS in which we overlaid logic regarding immunizations needed for CMCs. Using a randomized cluster-cross-over pragmatic clinical trial in four academic-affiliated clinics, we compared captured immunization opportunities during patient visits when the reminder was "on" versus "off" for the primary immunization series, school-age boosters, and adolescents. We also assessed coverage of CMC-specific immunizations. Up-to-date immunization was measured by end of quarter. Rates were compared using chi square tests.

RESULTS

 Overall, 15,343 unique patients were seen for 26,647 visits. The alert significantly impacted captured opportunities to complete the primary series in both well-child and acute care visits (57.6% on vs. 54.3% off, p = 0.001, and 15.3% on vs. 10.1% off, p = 0.02, respectively), among most age groups, and several immunization types. Captured opportunities for CMC-specific immunizations remained low regardless of alert status. The alert did not have an effect on up-to-date immunization overall (89.1 vs. 88.3%).

CONCLUSION

 CDS in this population improved captured immunization opportunities. Baseline high rates may have blunted an up-to-date population effect. Converting Centers for Disease Control and Prevention (CDC) rules to generate sufficiently sensitive and specific alerts for CMC-specific immunizations proved challenging, and the alert did not have an impact on CMC-specific immunizations, potentially highlighting need for more work in this area.

The Digital Way to Intercept Psoriatic Arthritis

Psoriasis (PsO) and Psoriatic Arthritis (PsA) are chronic, immune-mediated diseases that share common etiopathogenetic pathways. Up to 30% of PsO patient may later develop PsA. In nearly 75% of cases, skin psoriatic lesions precede arthritic symptoms, typically 10 years prior to the onset of joint symptoms, while PsO diagnosis occurring after the onset of arthritis is described only in 15% of cases. Therefore, skin involvement offers to the rheumatologist a unique opportunity to study PsA in a very early phase, having a cohort of psoriatic “risk patients” that may develop the disease and may benefit from preventive treatment. Progression from PsO to PsA is often characterized by non-specific musculoskeletal symptoms, subclinical synovio-entheseal inflammation, and occasionally asymptomatic digital swelling such as painless toe dactylitis, that frequently go unnoticed, leading to diagnostic delay. The early diagnosis of PsA is crucial for initiating a treatment prior the development of significant and permanent joint damage. With the ongoing development of pharmacological treatments, early interception of PsA has become a priority, but many obstacles have been reported in daily routine. The introduction of digital technology in rheumatology may fill the gap in the physician-patient relationship, allowing more targeted monitoring of PsO patients. Digital technology includes telemedicine, virtual visits, electronic health record, wearable technology, mobile health, artificial intelligence, and machine learning. Overall, this digital revolution could lead to earlier PsA diagnosis, improved follow-up and disease control as well as maximizing the referral capacity of rheumatic centers.

Pneumococcal Vaccination Among Lupus Patients: Who Are the Recipients?

PURPOSE

Pneumococcal vaccination (PV) is indicated for the elderly (age ≥65 years) and those with chronic disease or who are immunosuppressed. We aimed to study the rate and predictors of recommendation/receipt of 23 valent pneumococcal polysaccharide vaccine (PPSV23) in immunosuppressed systemic lupus erythematosus (SLE) patients.

METHODS

Data were obtained through self-report questionnaires and medical chart review of 150 SLE patients. Information on rheumatologist recommendation or receipt of PPSV23 in the preceding 5 years was collected if self-reported in a questionnaire or documented in the medical chart. Chart review was also done to collect data on patient demographics, physician characteristics (if patients had a primary care physician and rheumatologist's SLE patient volume), and the disease characteristics of SLE. Comparisons using χ2 or t tests and logistic regression analyses were conducted for predictors of recommendation/receipt of PV.

RESULTS

The mean (SD) age was 47.4 (15.9) years; 90% were women. Sixty-five of 94 eligible patients for PV (based on immunosuppressive medications use or age) had been either recommended or administered PPSV23. On univariate logistic regression analysis, age, duration of disease, current use of hydroxychloroquine or mycophenolate, and rheumatologist's SLE patient volume were significant correlates of recommendation/receipt of PPSV23. However, on multivariate analysis, the only significant predictor was rheumatologist's SLE patient volume after adjusting for the above correlates such that with every 50 patients increase in SLE patient clinic volume, the odds of recommendation/receipt of PPSV23 increased by 2.37 times.

CONCLUSIONS

The volume of lupus patients that rheumatologists see is strongly associated with the likelihood that their SLE patients will have PPSV23 recommended and delivered, suggesting a volume outcome relationship.

Interventions on health care providers to improve seasonal influenza vaccination rates among patients: a systematic review and meta-analysis of the evidence since 2000

BACKGROUND

Seasonal influenza vaccination (SIV) rates remain suboptimal in many populations, even in those with universal SIV.

OBJECTIVE

To summarize the evidence on interventions on health care providers (physicians/nurses/pharmacists) to increase SIV rates.

METHODS

We systematically searched/selected full-text English publications from January 2000 to July 2019 (PROSPERO-CRD42019147199). Our outcome was the difference in SIV rates between patients in intervention and non-intervention groups. We calculated pooled difference using an inverse variance, random-effects model.

RESULTS

We included 39 studies from 8370 retrieved citations. Compared with no intervention, team-based training/education of physicians significantly increased SIV rates in adult patients: 20.1% [7.5-32.7%; I2 = 0%; two randomized controlled trials (RCTs)] and 13.4% [8.6-18.1%; I2 = 0%; two non-randomized intervention studies (NRS)]. A smaller increase was observed in paediatric patients: 7% (0.1-14%; I2 = 0%; two NRS), and in adult patients with team-based training/education of physicians and nurses together: 0.9% (0.2-1.5%; I2 = 30.6%; four NRS). One-off provision of guidelines/information to physicians, and to both physicians and nurses, increased SIV rates in adult patients: 23.8% (15.7-31.8%; I2 = 45.8%; three NRS) and paediatric patients: 24% (8.1-39.9%; I2 = 0%; two NRS), respectively. Use of reminders (prompts) by physicians and nurses slightly increased SIV rates in paediatric patients: 2.3% (0.5-4.2%; I2 = 0%; two RCTs). A larger increase was observed in adult patients: 18.5% (14.8-22.1%; I2 = 0%; two NRS). Evidence from both RCTs and NRS showed significant increases in SIV rates with varied combinations of interventions.

CONCLUSIONS

Limited evidence suggests various forms of physicians' and nurses' education and use of reminders may be effective for increasing SIV rates among patients.

Sex Differences in Electronic Health Record Navigation Strategies: Secondary Data Analysis

Background

Use of electronic health records (EHRs) has increased dramatically over the past decade. Their widespread adoption has been plagued with numerous complaints about usability, with subsequent impacts on patient safety and provider well-being. Data in other fields suggest biological sex impacts basic patterns of navigation in electronic media.

Objective

This study aimed to determine whether biological sex impacted physicians’ navigational strategies while using EHRs.

Methods

This is a secondary analysis of a prior study where physicians were given verbal and written signout, and then, while being monitored with an eye tracker, were asked to review a simulated record in our institution’s EHR system, which contained 14 patient safety items. Afterward, the number of safety items recognized was recorded.

Results

A total of 93 physicians (female: n=46, male: n=47) participated in the study. Two gaze patterns were identified: one characterized more so by saccadic (“scanning”) eye movements and the other characterized more so by longer fixations (“staring”). Female physicians were more likely to use the scanning pattern; they had a shorter mean fixation duration (P=.005), traveled more distance per minute of screen time (P=.03), had more saccades per minute of screen time (P=.02), and had longer periods of saccadic movement (P=.03). The average proportion of time spent staring compared to scanning (the Gaze Index [GI]) across all participants was approximately 3:1. Females were more likely than males to have a GI value <3.0 (P=.003). At the extremes, males were more likely to have a GI value >5, while females were more likely to have a GI value <1. Differences in navigational strategy had no impact on task performance.

Conclusions

Females and males demonstrate fundamentally different navigational strategies while navigating the EHR. This has potentially significant impacts for usability testing in EHR training and design. Further studies are needed to determine if the detected differences in gaze patterns produce meaningful differences in cognitive load while using EHRs.

Uptake of influenza vaccination among persons with inflammatory bowel disease, multiple sclerosis or rheumatoid arthritis: a population-based matched cohort study

BACKGROUND

Individuals with immune-mediated inflammatory diseases, such as inflammatory bowel disease, multiple sclerosis and rheumatoid arthritis, are at increased risk for influenza and related complications. We examined and compared the uptake of influenza vaccination among people with and without these diseases, as well as the influence of psychiatric comorbidity on vaccine uptake.

METHODS

Using administrative data from Apr. 1, 1984, to Mar. 31, 2016, we conducted a retrospective matched cohort study in Manitoba, Canada. We matched persons 18 years of age or older who had a diagnosis of inflammatory bowel disease, multiple sclerosis or rheumatoid arthritis (the immune-mediated inflammatory disease cohorts) with persons who did not have these diagnoses (the control cohorts) on age, sex and region. We then identified cohort members with any mood or anxiety disorder (depression, anxiety disorders, bipolar disorder). We identified influenza vaccinations through billing codes. Using binomial regression, we modelled the difference in the proportion of the immune-mediated inflammatory disease and matched cohorts vaccinated annually, with adjustment for sociodemographic characteristics, comorbidity and immune therapy. We tested additive interaction effects between a person's cohort and presence of a mood or anxiety disorder.

RESULTS

We identified 32 880 individuals with 1 or more immune-mediated inflammatory diseases (10 148 with inflammatory bowel disease, 6158 with multiple sclerosis and 16 975 with rheumatoid arthritis) and a total of 164 152 controls. In fiscal year 2015, 8668 (41.3%, 95% confidence interval [CI] 40.6% to 42.0%) of the 20 982 persons with an immune-mediated inflammatory disease received an influenza vaccination, a rate higher than among controls (35 238 of 104 634; 33.7%, 95% CI 33.4% to 34.0%). After adjustment, participants with an immune-mediated inflammatory disease but no mood or anxiety disorder had 6.44% (95% CI 5.79% to 7.10%) greater uptake of vaccination than participants without such a disease. Among participants without an immune-mediated inflammatory disease, having a mood or anxiety disorder was associated with 4.54% (95% CI 4.20% to 4.89%) greater uptake of vaccination. However, we observed a subadditive interaction between immune-mediated inflammatory disease and psychiatric status (-1.38%, 95% CI -2.26% to -0.50%).

INTERPRETATION

Uptake of influenza vaccination was consistently low in populations with immune-mediated inflammatory disease, and although psychiatric morbidity is associated with greater vaccine uptake by Manitobans, it negatively interacts with these diseases to reduce uptake. Changes in care delivery are needed to mitigate this gap in care.

Improving population health in resident clinics: increasing pneumonia vaccination rates in adults 65 years and older

Streptococcus pneumoniae is a significant bacterial pathogen, especially in the elderly. There are two types of pneumococcal vaccines, one with polysaccharides from the capsule of 23 serotypes (PPSV23) and one with polysaccharides from 13 serotypes that have been conjugated to a protein (PCV13). Both vaccines decrease the incidence of invasive pneumococcal disease and are recommended for all people ≥65 years of age. We found the vaccination rate against S. pneumoniae in patients ≥65 years of age in our resident physician continuity clinics was 59.85%, which is considerably lower than the vaccination rate of 69.16% in our attending physician clinics. The aim of our study was to double the number of vaccinations given in the resident physician clinics over a 1-month period without compromising workflow or unduly burdening the rooming nurse or resident physicians. For our primary intervention, we assigned a designated nurse with expertise in vaccinations the task of reviewing charts ahead of clinic visits then pending the order for the appropriate pneumococcal vaccine. Our secondary intervention was the education of physicians through pocket cards, verbal encouragement and email reminders. χ² test was conducted to compare the proportion of patients 65 years or older who were vaccinated between the intervention and control groups. The results indicated that the intervention group patients were 2.61 times (95% CI 1.18 to 6.10) more likely to be vaccinated compared with the control group patients (20% vs 8.7%, χ² (1)=5.16, p=0.02, Cramer’s V=0.16). The intervention resulted in more than doubling the number of vaccinations in the intervention group compared with the control group. Moreover, poststudy interviews and surveys indicated our workflow is sustainable and amendable to wider use within the resident physician clinics.

Identifying perceptions and barriers regarding vaccination in patients with rheumatoid arthritis: A Canadian perspective

AIM

Canadian guidelines recommend that patients with rheumatoid arthritis (RA) receive pneumococcal, influenza and shingles vaccinations. The aim of this study was to identify and understand vaccination rates in Canadian patients with RA.

METHODS

We conducted an observational study to evaluate uptake of herpes zoster (HZ), influenza and pneumonia vaccination in a cross-section of patients with RA in Kingston, Ontario, Canada. Data were collected using a self-administered questionnaire in patients attending at an academic rheumatology clinic. If vaccination was not received, the reason was established.

RESULTS

Ninety-eight out of a total of 103 patients surveyed met the inclusion criteria and were evaluated: 72.4% had received the influenza vaccination in the past year encompassing a period of 2017-2019. Of the 27.6% who did not, the most common chosen reason was personal preference not to get vaccinated (55.6%). Regarding HZ, 18.4% had received vaccination. Of the 2 available types of vaccines, more participants received Zostavax (66.7%) as compared to Shringrix (33.3%). For those not vaccinated (81.6%), "Other" was the most chosen option (37.5%) with the reasons subsequently specified as cost, concern over interaction with treatment and waiting until age ≥65 years. In terms of pneumococcal vaccination, 36.7% were vaccinated, with the majority being vaccinated with Pneumovax-23 (63.9%) compared to Prevnar-13 (16.7%) or both (19.4%). Of the 63.3% of the participants who did not receive vaccination, the most cited reason was they did not know they should receive pneumococcal vaccination (48.4%).

CONCLUSIONS

Vaccination rates among Canadian patients with RA are suboptimal.

Digital health technologies: opportunities and challenges in rheumatology

The past decade in rheumatology has seen tremendous innovation in digital health technologies, including the electronic health record, virtual visits, mobile health, wearable technology, digital therapeutics, artificial intelligence and machine learning. The increased availability of these technologies offers opportunities for improving important aspects of rheumatology, including access, outcomes, adherence and research. However, despite its growth in some areas, particularly with non-health-care consumers, digital health technology has not substantially changed the delivery of rheumatology care. This Review discusses key barriers and opportunities to improve application of digital health technologies in rheumatology. Key topics include smart design, voice enablement and the integration of electronic patient-reported outcomes. Smart design involves active engagement with the end users of the technologies, including patients and clinicians through focus groups, user testing sessions and prototype review. Voice enablement using voice assistants could be critical for enabling patients with hand arthritis to effectively use smartphone apps and might facilitate patient engagement with many technologies. Tracking many rheumatic diseases requires frequent monitoring of patient-reported outcomes. Current practice only collects this information sporadically, and rarely between visits. Digital health technology could enable patient-reported outcomes to inform appropriate timing of face-to-face visits and enable improved application of treat-to-target strategies. However, best practice standards for digital health technologies do not yet exist. To achieve the potential of digital health technology in rheumatology, rheumatology professionals will need to be more engaged upstream in the technology design process and provide leadership to effectively incorporate the new tools into clinical care.

Scribes, EHRs, and Workflow Efficiencies in Allergy Practices

PURPOSE OF REVIEW

In the ever-changing healthcare system, along with new advancements in the field of allergy, the workflow for the allergist continues to evolve requiring more time spent doing non-clinical duties such as documentation and reviewing reimbursement challenges in the midst of busy clinics. The use of electronic medical records and medical scribes has emerged as tactics to aid the clinic's workflow and efficiency in the modern allergy and immunology clinic.

RECENT FINDINGS

The practicing allergist can implement various additional strategies in their office workflow to maximize and synthesize good medicine and good business. Optimal use of office staff, electronic health records, and various workflow efficiencies has been shown to improve job satisfaction and reduce physician burnout. By utilizing these methods and integrating them into their practices, allergists will be able to meet the demands of the healthcare system and still provide patients with evidence based, compassionate, and cost-effective care.

Longitudinal Evaluation of Clinical Decision Support to Improve Influenza Vaccine Uptake in an Integrated Pediatric Health Care Delivery System, Houston, Texas

OBJECTIVE

Our study retrospectively evaluated the implementation of an influenza vaccine best practice alert (BPA) in an electronic medical record within an integrated pediatric health care delivery system.

METHODS

An influenza BPA was implemented throughout a large pediatric health care delivery system in Houston, TX, to improve vaccine uptake. Outcomes were measured retrospectively over 3 years of BPA implementation and compared with a control year prior to BPA implementation. Primary outcomes were influenza vaccine uptake, distribution of influenza vaccines ordered by week, proportion of BPA displays ignored, and missed vaccination opportunities.

RESULTS

Influenza vaccine uptake declined from the pre-BPA year (47.2%; 95% confidence interval [CI]: 47.0, 47.4) to the last study year (45.1%; 95% CI: 44.9, 45.2). BPA displays were increasingly ignored by clinical staff throughout the study years from 59.6% in 2014-2015 to 72.5% in 2016-2017. For providers, BPA displays were ignored less frequently each year from 53.4% in 2014-2015 to 51.4% in 2017-2017. Within the primary care outpatient group, the proportion of missed vaccination opportunities in sick visits decreased from 86.8% during the pre-BPA year to 81.0, 79.8, and 82.7% during the subsequent study years 2014-2015, 2015-2016, and 2016-2017, respectively.

CONCLUSION

Implementation of a widespread influenza BPA in an integrated pediatric health care delivery system did not produce meaningful increases in influenza vaccine uptake. Differences between clinical staff and providers on BPA use warrant further investigation.

Suboptimal Immunization Coverage among Canadian Rheumatology Patients in Routine Clinical Care

OBJECTIVE

To assess vaccination coverage and predictors of vaccination among a Canadian population of rheumatology patients in routine clinical care.

METHODS

In this cross-sectional study, consecutive adult patients presenting to a tertiary rheumatology clinic at the McGill University Health Center between May and September 2015 were asked to fill a survey on vaccination. Patients self-identified as having rheumatoid arthritis (RA), systemic autoimmune rheumatic diseases (SARD), spondyloarthropathies (SpA), or other diseases (OD). Multivariate logistical regression analyses were performed to evaluate patient and physician factors associated with various vaccinations [for influenza, pneumococcus, and hepatitis B virus (HBV)]. Published Quebec general population influenza and pneumococcal vaccination rates in those aged ≥ 65 years were used as comparative baseline rates.

RESULTS

Three hundred fifty-two patients were included in the analysis (RA: 136, SARD: 113, SpA: 47, OD: 56). Vaccination rates were reported as follows: (1) influenza: RA 48.5%, SARD 42.0%, SpA 31.9%, OD 88.9%, Quebec general population 58.5%; (2) pneumococcal: RA 42.0%, SARD 37.8%, SpA 29.7%, OD 33.3%, Quebec general population 53.2%; (3) HBV: RA 33.6%, SARD 55.6%, SpA 73.5%, OD 36.8%; and (4) herpes zoster: RA 5.6%, SARD 28.6%, SpA 25.0%, OD 16.7%. Physician recommendation was the strongest independent predictor of vaccination across all vaccine types (influenza: OR 8.56, 95% CI 2.80-26.2, p < 0.001; pneumococcal: OR 314, 95% CI 73.0-1353, p < 0.001; HBV: OR 12.8, 95% CI 5.27-31.1, p < 0.001). Disease group, disease duration, comorbidities, treatment type, and being followed by a primary care physician were not significantly associated with vaccination.

CONCLUSION

There is suboptimal immunization coverage among ambulatory rheumatology patients. An important role for patient and physician education is highlighted in our study, especially because physician recommendation of vaccination was strongly predictive of vaccine uptake.

Impact of a guideline-based best practice alert on pneumococcal vaccination rates in adults in a primary care setting

BACKGROUND

Despite the high burden of pneumococcal disease, pneumococcal vaccine coverage continues to fall short of Healthy People 2020 goals. A quasi-experimental design was used to investigate the impact of pneumococcal-specific best-practice alerts (BPAs) with and without workflow redesign compared to health maintenance notifications only, on pneumococcal vaccination rates in at-risk and high-risk adults, and on series completion in immunocompetent adults aged 65+ years.

METHODS

This retrospective study used electronic health record and administrative data to identify pneumococcal vaccinations using cross sectional and historical cohorts of adults age 19+ years from 2013 to 2017 who attended clinics associated with the University of Utah Health. Difference-in-differences (DD) analyses was used to assess the impact of interventions across three observation periods (Baseline, Interim, and Follow Up). Adherence to the 2-dose vaccination schedule in older adults was measured through a longitudinal analysis.

RESULTS

In DD analyses, implementing both workflow redesign and the BPA raised the vaccination rate by 8 percentage points (pp) (P < 0.001) and implementing the BPA only raised the rate by 7 pp. (P < 0.001) among at-risk adults age 19-64 years, relative to implementing health maintenance notifications (i.e., usual care) only in comparison clinics. In high-risk adults age 19-64 years, the BPA with or without workflow redesign did not significantly affect vaccination rates from baseline to follow up relative to health maintenance notifications. Per DD analyses, the effect of the BPA was mixed in immunocompetent and immunocompromised adults age 65+ years. However, immunocompetent older adults attending a clinic that implemented the BPA plus health maintenance notifications and workflow redesign (all 3 interventions) had 1.94 times higher odds (Odds ratio (OR) 1.94; P = 0.0003, 95% CI 1.24, 3.01) to receive the second pneumococcal dose than patients attending a usual practice clinic (i.e., no intervention).

CONCLUSIONS

A pneumococcal BPA tool that reflects current guidelines implemented with and without workflow redesign improved vaccination rates for at-risk adults age 19-64 years and increased the likelihood of adults aged 65+ to complete the recommended 2-dose series. However, in other adult patient groups, the BPA was not consistently associated with improvements in pneumococcal vaccination rates.

A systematic review of interventions to improve uptake of pertussis vaccination in pregnancy

BACKGROUND

Maternal pertussis vaccination has been introduced in several countries to prevent pertussis morbidity and mortality in infants too young to be vaccinated. Our review aimed to systematically collect and summarize the available evidence on the effectiveness of interventions used to improve pertussis vaccination uptake in pregnant women.

METHODS

We conducted a systematic search of MEDLINE/PubMed, PMC and CINAHL. Before and after studies and those with a concurrent control group were considered for inclusion. Standardized effect sizes were described as the ratio of the odds to be vaccinated in the intervention group compared with the standard care group and absolute benefit increase (ABI) were calculated.

RESULTS

Six studies were included in the review, of which three were randomized controlled trials (RCTs). Strategies to improve uptake were focused on healthcare providers, pregnant women, or enhancing vaccine access. Healthcare provider interventions included provider reminder, education, feedback and standing orders. Interventions directed at pregnant women focused solely on education. Observational studies showed: (1) the provision of maternal pertussis vaccination by midwives at the place of antenatal care has improved uptake of pertussis vaccine during pregnancy from 20% to 90%; (2) introduction of an automated reminder within the electronic medical record was associated with an improvement in the pertussis immunization rate from 48% to 97%; (3) an increase in prenatal pertussis vaccine uptake from 36% to 61% after strategies to increase provider awareness of recommendations were introduced. In contrast to these findings, interventions in all three RCTs (2 involved education of pregnant women, 1 had multi-component interventions) did not demonstrate improved vaccination uptake.

CONCLUSIONS

Based on the existing research, we recommend incorporating midwife delivered maternal immunization programs at antenatal clinics, use of a provider reminder system to target unvaccinated pregnant women and include maternal pertussis immunization as part of standard antenatal care.

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

Introduction/objective

National guidelines emphasize the importance of annual immunization for patients living with rheumatoid arthritis (RA), but vaccination rates remain suboptimal in this population. Evaluating the efficacy of patient and/or provider-targeted interventions to improve vaccination uptake among RA patients could inform practice.

Methods

We conducted a systematic review (SR) to examine the efficacy of interventions (exposure) aiming to improve vaccination uptake in patients with RA (outcome). English and French language, peer-reviewed interventional studies to improve vaccination rates in RA patients published between 2009 and 2018 were included.

Results

The search yielded a total of 450 records. Five articles met inclusion criteria. All interventions focused on changing provider behavior using some form of vaccination reminder as the primary intervention strategy, though only two studies reported provider prescribing behavior as an outcome (which was 4% and 58%). Overall, studies varied greatly regarding intervention delivery mode (e.g., educational sessions, e-mail reminders, best practice alerts), and behavior change techniques used to encourage providers to prescribe vaccination (e.g., feedback and monitoring, shaping knowledge, self-regulation). For influenza, pneumococcal and herpes zoster, post-intervention (mean 12–16 months follow-up) vaccination rates increased by a mean of 16.6% (± 15.4%).

Conclusions

Interventions to enhance vaccine uptake in RA focused almost exclusively on improving provider prescription of vaccines using reminder-type interventions. Although effective in improving vaccination rates, those studies used heterogeneous interventions and behavior change techniques. Few studies measured provider prescribing behavior as an outcome. Future studies targeting providers should measure relevant provided-related outcomes and their impact on patient outcomes, to determine overall efficacy.

Effectiveness of a Best Practice Alerts at Improving Hypertension Control

BACKGROUND

Inadequately treated hypertension (HTN) leads to considerable morbidity and mortality. Despite many treatment options, blood pressure (BP) control is suboptimal. Missed opportunities due to the growing complexity of primary care office visits contribute. Electronic health records (EHRs) offer best practice alerts (BPA) tools to support clinicians in identifying poor BP control. BPAs have demonstrated effectiveness for other health outcomes.

METHODS

EHR data were collected for patients ≥18 years old seen for primary care office visits prior to, during, and after the BPA active period and used to identify patients for whom the BPA fired or would have fired during control periods. Logistic regression examined the association of BPA activation with follow-up BP check within 14-90 days and with BP control at follow-up, controlling for demographics and health conditions.

RESULTS

The BPA active period was associated with reduced patient follow-up; however, a number of covariates were predictive of increased follow-up: Black non-Hispanics, Hispanics, patients on the chronic kidney disease, HTN, or diabetes registries, as well as the morbidly obese, insurance status, and seasonal factors. For those who did follow-up, BPA activation was associated with improved BP control.

CONCLUSIONS

BPA activation was associated with worse patient follow-up but improved BP control. Some subgroups had significantly different rates of follow-up and BP control. This study did not have an experimental design as the BPA was a quality improvement initiative. These results highlight the critical importance of planning experimentally designed organizational initiatives to fully understand their impact.

Immunogenicity, safety and tolerability of anti-pneumococcal vaccination in systemic lupus erythematosus patients: An evidence-informed and PRISMA compliant systematic review and meta-analysis

The immunological perturbations associated with systemic lupus erythematosus (SLE) put many patients at a higher risk of infections, including pneumococcal pneumonia. However, the uptake and utility of anti-pneumococcal vaccines in SLE patient is both controversial and not completely agreed upon. Indeed, several epidemiological studies of anti-pneumococcal vaccine safety and efficacy in SLE have reported short-term immunogenicity with elevated anti-pneumococcal antibody titres but inconsistent long-term findings, with some studies finding poor responses, mainly for long-term immune protection. Moreover, the safety and efficacy of the pneumococcal vaccine in SLE patients remains controversial due to the different types of anti-pneumococcal vaccines, and the heterogeneity of SLE patients. Several reviews addressing anti-pneumococcal vaccination in SLE patients exist, however, to the best of our knowledge, the present is the first systematic review and meta-analysis. To better understand the efficacy and safety of pneumococcal vaccination in SLE, a comprehensive literature search was performed identifying 18 studies, which have been included in the present systematic review and meta-analysis. All studies were designed as longitudinal investigations, 2, in particular, were of high quality, being randomized, double-blind trials (RCTs). Four studies had control groups. Total sample size included 601 participants. Vaccine immunogenicity in terms of subjects with protective antibody titers ranged from 36% to 97.6%. According to our systematic review and metanalysis, high erythrocyte sedimentation rate (ESR), older age, earlier SLE onset, high disease activity, and immunosuppressive therapy were predictors of poor immunogenicity, although belimumab was found to have no significant impact. With regard to safety, no serious adverse events were found, with up to one third of cases reporting mild/low-grade complaints. In conclusion, due to the high risk of pneumococcal infection in SLE patients and given the safety and, at least partial, effectiveness, according to our systematic review and meta-analysis, in such patients, preventive strategies mainly by immunization, are required in all age groups and, in those needing immunosuppressive therapy, immunization should be given prior the initiation of the treatment. PROSPERO registration code CRD42018103605.

The use of technology to promote vaccination: A social ecological model based framework

Vaccinations are an important and effective cornerstone of preventive medical care. Growing technologic capabilities and use by both patients and providers present critical opportunities to leverage these tools to improve vaccination rates and public health. We propose the Social Ecological Model as a useful theoretical framework to identify areas in which technology has been or may be leveraged to target undervaccination across the individual, interpersonal, organizational, community, and society levels and the ways in which these levels interact.

Reducing Missed Opportunities for Influenza Vaccination in Patients with Rheumatoid Arthritis: Evaluation of a Multisystem Intervention

OBJECTIVE

To assess a multimodal intervention for reducing missed opportunities for outpatient influenza vaccination in individuals with rheumatoid arthritis (RA).

METHODS

Patients with RA were enrolled from a single center and each rheumatology outpatient visit was tracked for missed opportunities for influenza vaccination, defined as a visit in which an unvaccinated patient without contraindications remained unvaccinated or lacked documentation of vaccine recommendation in the electronic medical record (EMR). Providers then received a multimodal intervention consisting of an education session, EMR alerts, and weekly provider-specific e-mail reminders. Missed opportunities before and after the intervention were compared, and the determinants of missed opportunities were analyzed.

RESULTS

A total of 228 patients with RA were enrolled (904 preintervention visits) and 197 returned for at least 1 postintervention visit (721 postintervention visits). The preintervention frequency of any missed opportunities for influenza vaccination was 47%. This was reduced to 23% postintervention (p < 0.001). Among those vaccinated, the relative hazard for influenza vaccination post- versus preintervention period was 1.24 (p = 0.038). Younger age, less frequent office visits, higher erythrocyte sedimentation rate, and negative attitudes about vaccines were each independently associated with missed opportunities preintervention. Postintervention, these factors were no longer associated with missed opportunities; however, the intervention was not as effective in non-Hispanic black patients, non-English speakers, those residing outside of the New York City metropolitan area, and those reporting prior adverse reactions to vaccines.

CONCLUSION

Improved uptake of influenza vaccination in patients with RA is possible using a multimodal approach. Certain subgroups may need a more potent intervention for equivalent efficacy.

Significance of electronic health records: A comparative study of vaccination rates in patients with sickle cell disease

OBJECTIVE

In this study, we investigated the influence of electronic health records (EHR) and electronic vaccination schedule applications on the vaccination status of patients who were admitted to our Center for the treatment of sickle cell disease (SCD).

METHODS

The vaccination status against influenza and pneumococcus infection was determined in 93 patients who were admitted to the hematology outpatient clinic, Baskent University Adana Hospital from April 2004 to March 2009. The vaccination status was then re-evaluated following establishment of EHR and electronic vaccination schedules in 2012.

RESULTS

Of the 93 patients with SCD 21.5% (n = 20) were vaccinated against pneumococcus and 21.5% (n = 20) were regularly vaccinated against influenza. When the vaccination rates of 59 of 93 patients who presented for their regular control examinations were analyzed following establishment of EHR and vaccination schedules in 2012, these rates were 49.2% (n = 29) and 50.8% (n = 30) for influenza and pneumococcus, respectively, after EHR; there were 23.7% (n = 14) and 20.3% (n = 12), respectively, before EHR. A statistically significant difference was found between the vaccination rates before and after EHR (p < 0.05).

CONCLUSION

Although viral and bacterial infections are life-threatening health problems in patients with SCD, the vaccination rates were low in high-risk patients. However, these rates increased after application of electronic vaccination schedules.

Implementation of Electronic Health Records in US Nursing Homes

While electronic health records have emerged as promising tools to help improve quality of care, nursing homes have lagged behind in implementation. This study assessed electronic health records implementation, associated facility characteristics, and potential impact on quality indicators in nursing homes. Using national Centers for Medicare & Medicaid Services and survey data for nursing homes, a cross-sectional analysis was conducted to identify variations between nursing homes that had and had not implemented electronic health records. A difference-in-differences analysis was used to estimate the longitudinal effect of electronic health records on commonly used quality indicators. Data from 927 nursing homes were examined, 49.1% of which had implemented electronic health records. Nursing homes with electronic health records were more likely to be nonprofit/government owned (P = .04) and had a lower percentage of Medicaid residents (P = .02) and higher certified nursing assistant and registered nurse staffing levels (P = .002 and .02, respectively). Difference-in-differences analysis showed greater quality improvements after implementation for five long-stay and two short-stay quality measures (P = .001 and .01, respectively) compared with those who did not implement electronic health records. Implementation rates in nursing homes are low compared with other settings, and better-resourced facilities are more likely to have implemented electronic health records. Consistent with other settings, electronic health records implementation improves quality in nursing homes, but further research is needed to better understand the mechanism for improvement and how it can best be supported.

Using Active Choice Within the Electronic Health Record to Increase Influenza Vaccination Rates

BACKGROUND

Despite the benefits of influenza vaccination, each year more than half of adults in the United States do not receive it.

OBJECTIVE

To evaluate the association between an active choice intervention in the electronic health record (EHR) and changes in influenza vaccination rates.

DESIGN

Observational study.

PATIENTS

Adults eligible for influenza vaccination with a clinic visit at one of three internal medicine practices at the University of Pennsylvania Health System between September 2010 and March 2013.

INTERVENTION

The EHR confirmed patient eligibility during the clinic visit and, upon accessing the patient chart, prompted the physician and their medical assistant to actively choose to "accept" or "cancel" an order for the influenza vaccine.

MAIN MEASURES

Change in influenza vaccination order rates at the intervention practice compared to two control practices for the 2012-2013 flu season, comparing trends during the prior two flu seasons adjusting for time trends and patient and clinic visit characteristics.

KEY RESULTS

The sample (n = 45,926 patients) was 62.9% female, 35.9% white, and 54.4% black, with a mean age of 50.2 years. Trends were similar between practices during the 2 years in the pre-intervention period. Vaccination rates increased in both groups in the post-intervention year, but the intervention practice using active choice had a significantly greater increase than the control (adjusted difference-in-difference: 6.6 percentage points; 95% CI, 5.1-8.1; P < 0.001), representing a 37.3% relative increase compared to the pre-intervention period. More than 99.9% (9938/9941) of orders placed during the study period resulted in vaccination.

CONCLUSIONS

Active choice through the EHR was associated with a significant increase in influenza vaccination rates.

A systematic model improves hepatitis C virus birth cohort screening in hospital-based primary care

Despite national and local governing board recommendations in the United States of America to perform an HCV screening test in baby boomers, screening rates remain low. Our goal was to study the impact of an HCV screening and link-to-care programme with patient navigation in two New York City primary care practices. This was a 2-year prospective study of patients born between 1945-1965 ("baby boomers") with encounters at two primary care practices at the Mount Sinai Hospital between November 1, 2013 and November 30, 2015. Baseline HCV screening rates were collected for four months. A multifaceted intervention was sequentially implemented involving electronic alerts, housestaff education, data feedback and patient navigation. HCV screening rates and link to care, defined as attending an appointment with a viral hepatitis specialist, were compared before and after these interventions. There were 14 642 primary care baby boomer patients of which 4419 (30.2%) were newly screened during the study. There was a significant increase in HCV screening rates from 55% to 75% (P<.01) with an HCV seropositive rate of 3.3%. Factors associated with being HCV seropositive included older age (P<.01), male sex (P<.01), African American race (P<.01) and receiving care in the housestaff practice (P<.01). With patient navigation, 78 of 84 (93%) newly diagnosed HCV-infected persons were referred to a specialist and 60 (77%) attended their first appointment. A structured, multifaceted HCV screening programme using well-studied principles identifies a large number of undiagnosed baby boomers within hospital-based primary care and improves access to specialty providers in a timely manner.

A quality improvement initiative to increase pneumococcal vaccination coverage among children after kidney transplant

Pneumococcal vaccination rates among children receiving a kidney transplant remain suboptimal. Current practice guidelines in the United States recommend giving the PPSV23 after priming with the PCV13. We conducted a QI initiative to increase pneumococcal vaccine rates in our kidney transplant recipients by developing an age-based vaccine algorithm, obtaining vaccine records, and generating reminders for patients and clinicians. A monthly report from the EHR tracked outcomes. The process metric was missed vaccine opportunities, and the overall objective was to improve coverage with both the PCV13 and PPSV23. Over the first six months, we increased the percentage of visits where the vaccine was given from a baseline of 4% to 33%. However, by the end of the 12-month period, the percentage of eligible visits where the vaccine was given decreased to 8.7%. Nevertheless, over the 12-month observation period, we were able to increase the percentage of transplant patients receiving the PCV13 and PPSV23 from 6% to 52%. Utilizing an age-based algorithm and the electronic medical record, vaccine champions can track both missed visit opportunities and the number of vaccinated patients to improve pneumococcal immunization coverage for these high-risk patients.

Comparing guideline-based care quality for inflammatory bowel disease and rheumatoid arthritis patients within a medical home

BACKGROUND

Rheumatoid arthritis (RA) and inflammatory bowel disease (IBD) patient populations face similar risks of chronic immunosuppression including corticosteroid use. We compared the receipt of preventive services between IBD and RA populations according to published quality metrics.

METHODS

We defined a single-center cohort of patients with IBD or RA receiving specialty and primary care. Electronic health record abstraction assessed quality metrics, sociodemographics, comorbidity, and utilization. Comparisons used multivariate odds ratios and Student's t-tests.

RESULTS

218 RA and 190 IBD patients were included. In multivariate analysis, IBD patients were less likely to receive pneumococcal vaccination (OR=0.29, 95% CI: 0.11-0.85), while RA patients underwent glucocorticoid-induced osteoporosis screening more often (100% vs. 82.5%, p = 0.023).

CONCLUSIONS

Gastroenterologists can improve care quality for IBD patients by assuming greater responsibility for preventive care in IBD patients and/or collaborating with primary care and health systems to improve preventive care delivery.

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

OBJECTIVE

Vaccination rates for influenza, pneumococcus, and zoster in patients with rheumatoid arthritis (RA) 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 RA. 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% overall (p = 0.01) and from 3.0% to 6.6% among patients not receiving biologic therapy that precluded 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.

Successful introduction of an underutilized elderly pneumococcal vaccine in a national immunization program by integrating the pre-existing public health infrastructure

BACKGROUND

Although pneumococcal vaccines had been recommended for the elderly population in South Korea for a considerable period of time, the coverage has been well below the optimal level. To increase the vaccination rate with integrating the pre-existing public health infrastructure and governmental funding, the Korean government introduced an elderly pneumococcal vaccination into the national immunization program with a 23-valent pneumococcal polysaccharide vaccine in May 2013.

OBJECTIVE

The aim of this study was to assess the performance of the program in increasing the vaccine coverage rate and maintaining stable vaccine supply and safe vaccination during the 20 months of the program.

METHODS

We qualitatively and quantitatively analyzed the process of introducing and the outcomes of the program in terms of the systematic organization, efficiency, and stability at the national level.

RESULTS

A staggered introduction during the first year utilizing the public sector, with a target coverage of 60%, was implemented based on the public demand for an elderly pneumococcal vaccination, vaccine supply capacity, vaccine delivery capacity, safety, and sustainability. During the 20-month program period, the pneumococcal vaccine coverage rate among the population aged ≥65 years increased from 5.0% to 57.3% without a noticeable vaccine shortage or safety issues. A web-based integrated immunization information system, which includes the immunization registry, vaccine supply chain management, and surveillance of adverse events following immunization, reduced programmatic errors and harmonized the overall performance of the program.

CONCLUSION

Introduction of an elderly pneumococcal vaccination in the national immunization program based on strong government commitment, meticulous preparation, financial support, and the pre-existing public health infrastructure resulted in an efficient, stable, and sustainable increase in vaccination coverage.

Quality in rheumatoid arthritis care

While most rheumatology practices are characterized by strong commitment to quality of care and continuous improvement to limit disability and optimize quality of life for patients and their families, the actual step toward improvement is often difficult. This is because there are still barriers to be addressed and facilitators to be captured before a satisfying and cost-effective practice management is installed. Therefore, this review aims to assist practicing rheumatologists with quality improvement of their daily practice, focusing on care for rheumatoid arthritis (RA) patients. First we define quality of care as "the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge". Often quality is determined by the interplay between structure, processes, and outcomes of care, which is also reflected in the corresponding indicators to measure quality of care. Next, a brief overview is given of the current treatment strategies used in RA, focusing on the tight control strategy, since this strategy forms the basis of international treatment guidelines. Adherence to tight control strategies leads, also in daily practice, to better outcomes in patients with regard to disease control, functional status, and work productivity. Despite evidence in favor of tight control strategies, adherence in daily practice is often challenging. Therefore, the next part of the review focuses on possible barriers and facilitators of adherence, and potential interventions to improve quality of care. Many different barriers and facilitators are known and targeting these can be effective in changing care, but these effects are rather small to moderate. With regard to RA, few studies have tried to improve care, such as a study aiming to increase the number of disease activity measures done by a combination of education and feedback. Two out of the three studies showed markedly positive effects of their interventions, suggesting that change is possible. Finally, a simple step-by-step plan is described, which could be used by rheumatologists in daily practice wanting to improve their RA patient care.

Association of a Best-Practice Alert and Prenatal Administration With Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccination Rates

OBJECTIVE

To evaluate how implementation of a best-practice alert, a reminder of clinical guidelines within the electronic medical record, in combination with the recommended change in immunization timing from postpartum to antepartum, affected tetanus toxoid, reduced diphtheria toxoid and acellular pertussis (Tdap) rates, and to examine the association of vaccination with local pertussis attack rates.

METHODS

A Tdap best-practice alert was introduced into the electronic prenatal charting system in June 2013. The best-practice alert was designed to appear starting at 32 weeks of gestation and to reappear at every subsequent encounter until vaccine acceptance was recorded or delivery occurred. The overall acceptance rate was then compared with postpartum vaccination rates at our institution from the previous year. Records of pertussis cases in children younger than 2 years of age diagnosed since 2012 in Dallas County were also reviewed to correlate local trends with vaccination efforts.

RESULTS

Of the 10,201 women offered Tdap during prenatal care, 9,879 (96.8%) ultimately accepted. This is compared with a 48% (5,064 of 10,600) Tdap postpartum immunization rate in the year prior, before introduction of the best-practice alert. The incidence of pertussis among neonates born to mothers who received prenatal care at Parkland Hospital showed a nonsignificant decline from 13 cases per 10,000 deliveries (19 of 14,834, 95% confidence interval [CI] 7-19) between January 2012 and May 2013 to seven per 10,000 deliveries during the study period (eight of 11,788, 95% CI 2-11, P=.174).

CONCLUSION

The use of a best-practice alert, in concert with the recommended change in timing of maternal vaccination from postpartum to antepartum, was associated with an increase in the Tdap immunization rate to 97%.

LEVEL OF EVIDENCE

II.

Improving Influenza and Pneumococcal Vaccination Rates in Ambulatory Specialty Practices

Background. Influenza and pneumococcal vaccinations are recommended for elderly and high-risk patients; however, rates of adherence are low. We sought to implement influenza and pneumococcal vaccine initiatives in 4 different ambulatory specialty practices, using 3 unique approaches.

Methods. Four specialties with high-risk patient populations were selected for intervention: allergy (asthma), infectious disease (ID) (human immunodeficiency virus), pulmonary (chronic lung disease), and rheumatology (immunocompromised). Allergy and ID focused on influenza vaccination, and pulmonary and rheumatology focused on pneumococcal vaccination. We used 3 strategies for quality improvement: physician reminders, patient letters, and a nurse-driven model. Physicians were provided their performance data on a monthly basis and presented trended data on a quarterly basis at staff meetings.

Results. All 4 specialties developed processes for improving vaccination rates with all showing some increase. Higher rates were achieved with pneumococcal vaccine than influenza. Pneumococcal vaccine rates showed steady improvement from year to year while influenza vaccine rates remained relatively constant. Allergy's influenza rate was 59% in 2011 and 64% in the 2014 flu season. Infectious disease influenza rates moved from 74% in the 2011 flu season to 86% for the 2014 season. Pneumococcal vaccine in pulmonary patients' rate was 52% at the start of intervention in February 2009 and 79% as of January 2015. Rheumatology rates rose from 50% in February 2009 to 87% in January 2015.

Conclusions. Integrated routine workflow and performance data sharing can effectively engage specialists and staff in vaccine adherence improvement. Influenza vaccination may require other approaches to achieve the rates seen with pneumococcal vaccine.

Development, Evaluation and Implementation of Chief Complaint Groupings to Activate Data Collection: A Multi-Center Study of Clinical Decision Support for Children with Head Trauma

BACKGROUND

Overuse of cranial computed tomography scans in children with blunt head trauma unnecessarily exposes them to radiation. The Pediatric Emergency Care Applied Research Network (PECARN) blunt head trauma prediction rules identify children who do not require a computed tomography scan. Electronic health record (EHR) based clinical decision support (CDS) may effectively implement these rules but must only be provided for appropriate patients in order to minimize excessive alerts.

OBJECTIVES

To develop, implement and evaluate site-specific groupings of chief complaints (CC) that accurately identify children with head trauma, in order to activate data collection in an EHR.

METHODS

As part of a 13 site clinical trial comparing cranial computed tomography use before and after implementation of CDS, four PECARN sites centrally developed and locally implemented CC groupings to trigger a clinical trial alert (CTA) to facilitate the completion of an emergency department head trauma data collection template. We tested and chose CC groupings to attain high sensitivity while maintaining at least moderate specificity.

RESULTS

Due to variability in CCs available, identical groupings across sites were not possible. We noted substantial variability in the sensitivity and specificity of seemingly similar CC groupings between sites. The implemented CC groupings had sensitivities greater than 90% with specificities between 75-89%. During the trial, formal testing and provider feedback led to tailoring of the CC groupings at some sites.

CONCLUSIONS

CC groupings can be successfully developed and implemented across multiple sites to accurately identify patients who should have a CTA triggered to facilitate EHR data collection. However, CC groupings will necessarily vary in order to attain high sensitivity and moderate-to-high specificity. In future trials, the balance between sensitivity and specificity should be considered based on the nature of the clinical condition, including prevalence and morbidity, in addition to the goals of the intervention being considered.

Attitude, knowledge and factors associated with influenza and pneumococcal vaccine uptake in a large cohort of patients with secondary immune deficiency

BACKGROUND

Immunocompromised patients are at increased risk for severe influenza and invasive pneumococcal diseases. Population-specific vaccine recommendations are thus warranted. This study aimed to estimate the prevalence and predictors of influenza and pneumococcal vaccine uptake in a large cohort of patients with secondary immune deficiency.

METHODS

An anonymous online survey was submitted to the members of 11 French associations of immunocompromised patients. The questionnaire included questions concerning underlying disease, care and treatment, flu and pneumococcal vaccine uptake, attitudes and knowledge about vaccination. Factors associated with vaccine uptake were assessed by multivariate logistic regression.

RESULTS

Among the 10,897 solicited patients, 3653 agreed to participate (33.5%): 75% were female, 20% aged 65+, 79% were followed for an autoimmune disease, 13% were solid organ recipients or waiting for transplantation and 8% were treated for hematological malignancies. 3109 (85%) participants were treated with immunosuppressive therapy. Self-reported vaccine uptake was 59% (95%CI [57-60]) against seasonal influenza and 49% (95%CI [47-50]) against pneumococcal diseases. Better knowledge of and favorable attitudes toward vaccination were positively associated with vaccine uptake while being treated with a biological therapy was negatively associated.

CONCLUSION

Despite specific recommendations regarding immunocompromised patients, influenza and pneumococcal vaccination rates do not reach recommended levels. Targeted information campaigns on vaccination toward these populations should be implemented to improve vaccine coverage and thus reduce the burden of infections.

Improvement in influenza vaccination rates in a pediatric sickle cell disease clinic

BACKGROUND

Children with sickle cell disease (SCD) are at increased risk of complications from influenza. However, despite widespread recommendations that these patients receive an annual influenza immunization, reported vaccination rates remain very low at under 50%.

PROCEDURE

Our aim was to increase the influenza vaccination rate among our pediatric patients with SCD aged 6 months to 21 years over two influenza seasons, 2012-2013 and 2013-2014, to 80%, consistent with the Health People 2020 goal. We used multiple quality improvement methods, based on the literature and our previous experience in other aspects of SCD care, including parent and provider education, enhancement of our EHR, use of a SCD patient registry and reminder and recall done by a patient navigator.

RESULTS

We vaccinated 80% of our pediatric patients with SCD for influenza during the 2012-2013 season and 90% of patients in 2013-2014. Our early season vaccination rates were nearly double that of those for the general population.

CONCLUSIONS

Use of quality improvement methods can increase rates of influenza vaccination for this high-risk population, suggesting that less health care utilization and lower cost might result.

Vaccinations for rheumatoid arthritis

Patients with rheumatoid arthritis (RA) suffer an increased burden of infectious disease-related morbidity and mortality and have twice the risk of acquiring a severe infection compared to the general population. This increased risk is not only a result of the autoimmune disease but is also attributed to the immunosuppressive therapies that are commonly used in this patient population. Given the increase in infection-related risks in RA, there is great interest in mitigating such risk. A number of vaccines are available to the rheumatologist, with a handful that are of importance for RA patients in the United States. The goal of this paper is to highlight the most recent literature on the key vaccines and the specific considerations for the rheumatologist and their RA patients, with a particular focus on influenza, pneumococcal, and herpes zoster vaccines. It is important for rheumatologist to understand and be aware of which vaccines are live and what potential contraindications exist for giving vaccines to RA patients.

Use of electronic health record-based tools to improve appropriate use of the human papillomavirus test in adult women

OBJECTIVE

To determine whether compliance with guidelines for cervical cancer screening, particularly use of the human papillomavirus (HPV) test in adult (aged ≥21 y) women, improves with the implementation of educational prompts in the electronic health record (EHR).

MATERIALS AND METHODS

Two EHR-based interventions aimed at reducing unindicated HPV tests were implemented in the EHR in late June 2010. The Pap order form was revised with a descriptor next to the cotest (Pap plus HPV test) option advising that this is not for screening in women younger than 30 years, and a link to the American Society for Colposcopy and Cervical Pathology Web site was made available on the EHR home page. Charts of adult women with HPV results from January to December 2010 were reviewed. Appropriateness of HPV test ordering before (period A: from January to June) and after (period B: from July to December) the interventions were compared using the χ(2) test of association.

RESULTS

A total of 3,564 HPV tests were performed on adult women at Loyola University Medical Center in 2010. During period A, 1,709 tests were ordered compared with 1,855 tests ordered during period B (p = .014). The proportion of HPV tests without an appropriate indication decreased significantly after the EHR changes (20% for period A vs 13% for period B, p < .0005). This significant decrease was seen in both primary care (22% in period A vs 12% in period B, p < .0005) and obstetrics and gynecology (Ob/Gyn) (19% vs 13%, p < .0005).

CONCLUSIONS

Electronic health record-based tools improve compliance with cervical cancer screening guidelines.