Improving a process to obtain hepatitis B serology among patients treated with infliximab at a large urban children's hospital

Improving Hepatitis B Vaccination Rates among At-risk Children and Adolescents with Inflammatory Bowel Disease

Patients with inflammatory bowel disease (IBD) receiving tumor necrosis factor alpha inhibitors (TNFai) may be at higher risk for hepatitis B virus (HBV) infection. We conducted a quality improvement (QI) initiative to improve HBV vaccination rates in seronegative children with IBD.

Methods

This QI initiative implemented an HBV vaccination strategy from September 2018 to March 2020 in patients with newly diagnosed IBD with hepatitis B surface antibody (HBsAb) <10 mIU/mL. The project aimed to (1) increase HBV vaccination rates in seronegative patients and (2) document immunogenicity after completing a three-dose vaccine series. Outcome measures included the percentage of seronegative patients who received HBV vaccines (dose 1 and three-dose series). Interventions included applying a standardized vaccination protocol, and creating a vaccine workflow in two clinical areas, previsit planning and stakeholder engagement.

Results

One hundred seventy-four children and adolescents with IBD were evaluated during the study period, and 132 (76%) were HBsAb negative. After plan-do-study-act (PDSA) 1, the proportion of eligible patients who received HBV vaccine dose 1 increased from a baseline of 7% to 100% and was sustained for over 12 months. During PDSA 2, the proportion of patients completing the three-dose vaccine series improved from a baseline of 0% to 82% (n = 100); among 93 children in this subgroup who had repeat serology performed, 86 (92%) demonstrated serologic evidence of HBV protection.

Conclusions

A multidisciplinary approach applying QI methodology allowed for improved and sustained HBV vaccination rates in at-risk seronegative children and adolescents with IBD. A three-dose HBV vaccine series proved immunogenic in 92% of eligible patients.

Technology-Enabled and Artificial Intelligence Support for Pre-Visit Planning in Ambulatory Care: Findings From an Environmental Scan

PURPOSE

Pre-visit planning (PVP) is believed to improve effectiveness, efficiency, and experience of care, yet numerous implementation barriers exist. There are opportunities for technology-enabled and artificial intelligence (AI) support to augment existing human-driven PVP processes-from appointment reminders and pre-visit questionnaires to pre-visit order sets and care gap closures. This study aimed to explore the current state of PVP, barriers to implementation, evidence of impact, and potential use of non-AI and AI tools to support PVP.

METHODS

We used an environmental scan approach involving: (1) literature review; (2) key informant interviews with PVP experts in ambulatory care; and (3) a search of the public domain for technology-enabled and AI solutions that support PVP. We then synthesized the findings using a qualitative matrix analysis.

RESULTS

We found 26 unique PVP implementations in the literature and conducted 16 key informant interviews. Demonstration of impact is typically limited to process outcomes, with improved patient outcomes remaining elusive. Our key informants reported that many PVP barriers are human effort-related and see potential for non-AI and AI technologies to support certain aspects of PVP. We identified 8 examples of commercially available technology-enabled tools that support PVP, some with AI capabilities; however, few of these have been independently evaluated.

CONCLUSIONS

As health systems transition toward value-based payment models in a world where the coronavirus disease 2019 pandemic has shifted patient care into the virtual space, PVP activities-driven by humans and supported by technology-may become more important and powerful and should be rigorously evaluated.

Vaccination for Children on Biologics

PURPOSE OF REVIEW

Several biologic drugs are available for treatment of immune-mediated diseases, and the number of children treated with biologics is increasing. This review summarises current knowledge about the safety and immunogenicity of vaccines in children treated with biologic therapy.

RECENT FINDINGS

A recent retrospective, multicentre study reported that the booster dose of live-attenuated vaccine (MMR/V) was safe for patients with rheumatic diseases treated with biologic therapy. Recent publications revealed that immunogenicity of vaccines in children treated with biologics was lower than in the healthy population, especially on long-term follow-up. Children treated with biologic therapy are at greater danger of infections, compared to the healthy population. Therefore, they should be vaccinated according to national guidelines. Regardless of the therapy, non-live vaccines are recommended. However, it is common practice to advise postponing vaccination with live-attenuated vaccines in children while they are on immunosuppressive therapy. Newly published data suggest that booster dose MMR/V is safe for children treated with biologic therapy.