Improving the Combination Pneumococcal Vaccination Rate in Systemic Lupus Erythematosus Patients at an Adult Rheumatology Practice

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.

Do Not Leave Your Patients in the Dark-Using American College of Rheumatology and European Alliance of Associations for Rheumatology Recommendations for Vaccination in Polish Adult Patients with Autoimmune Inflammatory Rheumatic Diseases

(1) Introduction: Patients with autoimmune inflammatory rheumatic diseases (AIIRD) face a higher infectious risk compared to the general population. As per the ACR and EULAR recommendations, vaccinations against influenza, COVID-19, pneumococci, and tetanus are recommended for most patients with AIIRD. (2) Objectives: This study aimed to assess vaccination coverage among Polish AIIRD patients and identify factors influencing it. (3) Patients and Methods: This study was conducted at the reference rheumatological center in Poland between May 2023 and October 2023. The study participants completed a questionnaire covering their knowledge of vaccination recommendations, actual vaccination status, factors affecting their decision to vaccinate, and their perspectives on immunization. (4) Results: This study involved 300 AIIRD patients and 60 controls. Both groups exhibited comparably low vaccination rates for all diseases (the highest for COVID-19-52% in both groups and the lowest for pneumococci-7.7% and 10%, respectively). Knowledge about recommended vaccinations was limited among patients in both groups. AIIRD patients were also not aware that they should avoid live vaccines. The primary motivators for vaccination among AIIRD patients were fear of infection (up to 75%) and medical advice (up to 74.6%). Conversely, the predominant reasons for non-vaccination were a lack of knowledge that vaccination is recommended (up to 74.7%) and concerns about potential adverse effects (up to 48.6%). Many patients reported not receiving vaccination recommendations from either primary care physicians or rheumatologists. (5) Conclusions: To enhance vaccination coverage among AIIRD patients in Poland, it is essential to educate them about vaccinations during routine medical consultations, emphasizing the increased risk of infection, informing them about recommended vaccinations, and clarifying doubts about adverse effects.

A survey of systemic lupus erythematosus patients' attitudes toward influenza and pneumococcal vaccination in Southwest China

Introduction

Vaccination is the most effective measure for prevention against infectious diseases in patients with systemic lupus erythematosus (SLE). Therefore, it is important to know SLE patients' attitudes toward influenza and pneumococcal vaccination. This study aimed to investigate the attitude toward influenza and pneumococcal vaccination among SLE patients in Southwest China and its influencing factors.

Methods

A web-based questionnaire was conducted to collect data regarding SLE patients' demographics, history of infections, medications, comorbidities, attitudes toward infection and vaccination, rates of influenza and pneumococcal vaccination, and role of health professionals in promoting vaccination. Univariate and multivariate logistic regression analyses were conducted to assess the vaccination willingness-associated factors.

Results

A total of 251 patients participated in the survey and 240 questionnaires were completed and statistically analyzed. The influenza and pneumococcal vaccination rates were 8.3 and 1.7%, respectively. The top three reasons for non-vaccination were worrying about the SLE exacerbation or flare resulting from the vaccine or its adjuvants, being concerned about adverse events, and the lack of awareness of vaccine availability. More than half of the participants were willing to be vaccinated against influenza (56.2%) and pneumococcus (52.9%). Factors associated to the willingness to receive the influenza vaccine and pneumococcal vaccine were being afraid of infection, believing in the efficacy of influenza vaccination, lower family income, less perceived care from family members, perceived susceptibility to pneumococcal infection, and perceiving influenza and pneumococcal vaccination as beneficial for health.

Conclusions

The influenza and pneumococcal vaccination rates are low among SLE patients in Southwest China. The positive perspective of vaccination on health represented the most impacting factor on their willingness to undergo influenza and pneumococcal vaccination. Non-vaccinated patients were mainly concerned about exacerbation of the disease or adverse events caused by vaccines. It is important to improve the compliance with the guideline-recommended roles of health professionals and to promote the collaboration between rheumatology and primary care teams.

Improving Pneumococcal Vaccination Rates in High-risk Children in Specialty Clinics

BACKGROUND AND OBJECTIVES

Pediatric patients with immunocompromising or certain chronic medical conditions have an increased risk of acquiring invasive pneumococcal disease (IPD). The 23-valent pneumococcal polysaccharide vaccine (PPSV23) is recommended for patients ≥2 years at high risk for IPDs. The aim of this project was to improve PPSV23 vaccination rates for children at high risk for IPD who were seen in 3 specialty clinics from ∼20% to 50% over a 12-month period.

METHODS

The project team included quality improvement champions from the divisions of rheumatology, infectious diseases, and pulmonology in addition to leaders from our population health management subsidiary. Several initiatives were implemented, starting with review of patient inclusion criteria per the vaccination recommendations, that led to the design and deployment of an automated weekly previsit planning report. Additionally, we implemented a process to stock pneumococcal vaccines and shared best practices among the divisions. We monitored improvement through times series and run charts of PPSV23 vaccination rates.

RESULTS

The initial PPSV23 vaccination rate for applicable high-risk patients was ∼20%. There was an increase in vaccination rate to ∼60%. All 3 divisions showed improvements in their individual PPSV23 vaccination rates.

CONCLUSIONS

Using quality improvement methodology, we increased PPSV23 vaccination rates in 3 pediatric specialty clinics, and this improvement was sustained. We will continue to identify best practices and actively recruit additional divisions because we have the opportunity to reach >9000 high-risk patients.

Flu and Pneumococcal Vaccine Coverage in Scleroderma Patients Still Need to Be Prompted: A Systematic Review

Systemic sclerosis (scleroderma, SSc) is an autoimmune connective tissue disease characterized by excessive production of collagen and multiorgan involvement. Scleroderma patients are at increased risk of influenza complications and pneumonia; thus, vaccinations are recommended. This systematic review evaluated the influenza and pneumococcus vaccination coverage for SSc patients. We included all studies from Pubmed reporting on influenza and pneumococcal vaccination rate in Scleroderma patients up to May 2021. The 14 studies thus selected identified a suboptimal vaccination rate in autoimmune and SSc patients, ranging from 28 to 59% for the flu vaccine, and from 11 to 58% for the pneumo vaccine in absence of specific vaccination campaigns, variously considering also other variables such as age, gender, vaccination settings, and possible vaccination campaigns. We also considered the reasons for low coverage and the approaches that might increase the vaccination rates. A lack of knowledge about the importance of vaccination in these patients and their doctors underlined the need to increase the awareness for vaccination in this patients' category. Current guidelines recommend vaccination in elderly people and people affected by particular conditions that widely overlap with SSc, yet autoimmune diseases are not always clearly mentioned. Improving this suboptimal vaccination rate with clear guidelines is crucial for SSc patients and for clinicians to immunize these categories based principally on the pathology, prior to the age. Recommendations by the immunologist and the direct link to the vaccine providers can highly improve the vaccine coverage.

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.

Avoidable Acute Care Use for Vaccine-Preventable Illnesses Among Medicaid Beneficiaries With Lupus

OBJECTIVE

Nearly 25% of patients with systemic lupus erythematosus (SLE) are hospitalized yearly, often for outcomes that may have been avoided if patients had received sustained outpatient care. We examined acute care use for vaccine-preventable illnesses to determine sociodemographic contributors and modifiable predictors.

METHODS

Using US Medicaid claims from 29 states (2000-2010), we identified adults (18-65 years) with prevalent SLE and 12 months of enrollment prior to the first SLE code (index date) to identify baseline data. We defined acute care use for vaccine-preventable illnesses as emergency department (ED) or hospital discharge diagnoses for influenza, pneumococcal disease, meningococcal disease, herpes zoster, high-grade cervical dysplasia/cervical cancer, and hepatitis B after the index date. We estimated the incidence rate of vaccine-preventable illnesses and used Cox regression to assess risk (with hazard ratios and 95% confidence intervals) by sociodemographic factors and health care utilization, adjusting for vaccinations, comorbidities, and medications.

RESULTS

Among 45,654 Medicaid beneficiaries with SLE, <10% had billing claims for vaccinations. There were 1,290 patients with ≥1 ED visit or hospitalization for a vaccine-preventable illness (6.6 per 1,000 person-years); 93% of events occurred in unvaccinated patients. Patients who were Black compared to White had 22% higher risk. Greater outpatient visits were associated with lower risk.

CONCLUSION

Medicaid beneficiaries with SLE who are not vaccinated are at risk for potentially avoidable acute care use for vaccine-preventable illnesses. Racial disparities were noted, with a higher risk among Black patients compared to White patients. Greater outpatient use was associated with reduced risk, suggesting that access to ambulatory care may reduce avoidable acute care use.

Hospitalized Infections in Lupus: A Nationwide Study of Types of Infections, Time Trends, Health Care Utilization, and In-Hospital Mortality

OBJECTIVE

To examine the time trends in hospitalized infections in patients with systemic lupus erythematosus (SLE), and the factors associated with health care utilization and in-hospital mortality.

METHODS

US National Inpatient Sample data from 1998-2016 were used to examine the epidemiology, time trends, and outcomes of 5 common hospitalized infections in patients with SLE, namely, pneumonia, sepsis/bacteremia, urinary tract infection (UTI), skin and soft tissue infections (SSTIs), and opportunistic infections (OIs). Time trends were compared using the Cochran-Armitage test. Multivariable-adjusted logistic regression models were used to examine the factors associated with health care utilization (hospital stay >3 days, hospital charges above the median, or discharge to a nonhome setting) and in-hospital mortality.

RESULTS

Hospitalization rates per 100,000 claims among SLE patients in 1998-2000 versus in 2015-2016 were as follows: for OIs, 1.13 versus 1.61 (1.2-fold increase); for SSTIs, 4.78 versus 12.2 (2.5-fold increase); for UTI, 1.94 versus 6.12 (3.2-fold increase); for pneumonia, 15.09 versus 17.05 (1.1-fold increase); and for sepsis, 6.31 versus 39.64 (6.3-fold increase). In 2011-2012, sepsis surpassed pneumonia as the most common hospitalized infection in patients with SLE. In multivariable-adjusted models, a diagnosis of sepsis, older age, a Deyo-Charlson common comorbidities score of ≥2, having Medicare or Medicaid insurance, and urban hospital location were significantly associated with increased odds of in-hospital mortality and with all health care utilization outcomes. African American race was significantly associated with increased odds of health care utilization.

CONCLUSION

The results of this study indicate that the rates of hospitalized infections increased over time in patients with SLE, and that pneumonia was surpassed by sepsis as the most common hospitalized infection. In addition, associations of risk factors with poorer outcomes were identified. These findings may help inform patients, providers, and policy makers with regard to the burden of infection in SLE, and could lead to interventions/pathways to improve outcomes.

Infections in the Era of Targeted Therapies: Mapping the Road Ahead

Immunosuppressive treatment strategies for autoimmune diseases have changed drastically with the development of targeted therapies. While targeted therapies have changed the way we manage immune mediated diseases, their use has been attended by a variety of infectious complications—some expected, others unexpected. This perspective examines lessons learned from the use of different targeted therapies over the past several decades, and reviews existing strategies to minimize infectious risk. Several of these infectious complications were predictable in the light of preclinical models and early clinical trials (i.e., tuberculosis and TNF inhibitors; meningococcus; and eculizumab). While these scenarios can potentially help us in terms of enhancing our predictive powers (higher vigilance, earlier detection, and risk mitigation), targeted therapies have also revealed unpredictable toxicities (i.e., natalizumab and progressive multifocal leukoencephalopathy). Severe infectious complications, even if rare, can derail a promising therapeutic and highlight the need for increased awareness and meticulous adjudication. Tools are available to help mitigate infectious risks. The first step is to ensure that infection safety is adequately studied at every level of drug development prior to regulatory approval, with adequate post-marketing surveillance including registries that collect real-world adverse events in a collaborative effort. The second step is to identify high risk patients (using risk calculators such as the RABBIT risk score; big data analyses; artificial intelligence). Finally, the most underutilized interventions to prevent severe infections in patients receiving targeted therapies across the spectrum of immune mediated inflammatory diseases are vaccinations.

Systemic lupus erythematosus and risk of infection

INTRODUCTION

Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects almost every organ system and it is treated with immunomodulation and immunosuppression. SLE patients have an intrinsically dysfunctional immune system which is exacerbated by disease activity and leaves them vulnerable to infection. Treatment with immunosuppression increases susceptibility to infection, while hydroxychloroquine use decreases this risk. Infectious diseases are a leading cause of hospitalization and death.

AREAS COVERED

This narrative review provides an overview of recent epidemiology and predictors of infections in SLE, delineates the risk of infection by therapeutic agent, and provides suggestions for risk mitigation. Articles were selected from Pubmed searches conducted between September 2019 and January 2020.

EXPERT OPINION

Despite the large burden of infection, effective and safe preventative care such as universal hydroxychloroquine use and vaccination are underutilized. Future efforts should be directed to quality improvement, glucocorticoid reduction, and validation of risk indices that identify patients at the highest risk of infection.

Previsit Planning Improves Pneumococcal Vaccination Rates in Childhood-Onset SLE

BACKGROUND

Childhood-onset systemic lupus erythematosus (c-SLE) is a complex autoimmune disease that requires systemic immunosuppressive therapy. Infections are the second leading cause of death in these patients, with invasive pneumococcal infections being a major preventable cause of morbidity and mortality. Pneumococcal vaccination is recommended in this population; however, vaccination rates remain low.

METHODS

The plan-do-study-act method of quality improvement was applied. We calculated baseline vaccination rates for pneumococcal conjugate and pneumococcal polysaccharide vaccines in patients with c-SLE in the rheumatology clinic from January 2015 to August 2016. We developed an age-based algorithm to simplify the vaccination guidelines. The clinical pharmacist and nurses performed weekly previsit planning to update vaccine records, make targeted recommendations, and ensure vaccine availability. The primary outcome measure was the percentage patients with of c-SLE seen per month who had received age-appropriate pneumococcal vaccination.

RESULTS

The percentage of children receiving at least 1 pneumococcal vaccine increased from 24.9% to 92.7% by 12 months. By 18 months, the compliance rate with both pneumococcal vaccines increased from 2.5% to 87.3%, with sustained results. No serious adverse events or disease flares were reported.

CONCLUSIONS

By identifying the major barriers to pneumococcal vaccination in our population with c-SLE, we significantly improved vaccination rates while decreasing time burden on providers. We attribute our success to a team-based quality improvement approach and plan to implement alerts in the electronic health record to streamline the process.