1. The Ohio State University, Columbus, Ohio
Pre-visit Planning Improves Pneumococcal Vaccination in Patients with Childhood-onset Systemic Lupus Erythematosus Kelly Wise1, Fatima Barbar-Smiley1, Monica Ardura2, William Cotton3, Evan Mulvihill1, Ohoud Al Ahmed1, Darby MacDonald1, Stephanie Lemle1, Cagri Yildirim-Toruner1, Vidya Sivaraman1
Divisions of Rheumatology1, Infectious Diseases2 and Primary Care3, Nationwide Children’s Hospital and
The Ohio State University, Columbus, Ohio
18.6 age
Background
Figure 1. Key Driver Diagram
Figure 3. Patients Receiving ≥ 1 Age-Appropriate Pneumococcal Vaccine
Patients with Systemic Lupus Erythematosus (SLE) are at an increased risk for infections due to inherent immune abnormalities and long term immunosuppressive therapy.
In particular, invasive pneumococcal infections are up to 13 times more likely to occur in these patients, resulting in increased morbidity and mortality [1].
Vaccination against S. pneumoniae is recommended for all patients with SLE [2, 3], however, vaccination rates in routine rheumatology care remain low.
Barriers to vaccination include [4]:
- Lack of provider recommendation
- Concerns about vaccine efficacy and safety
- Lack of vaccine supply in subspecialty clinics
- Incomplete immunization records
- Lack of time
Here we report the results 12 months after initiating a quality improvement project to improve pneumococcal vaccination rates in patients with Childhood-onset SLE (c-SLE) in a pediatric rheumatology clinic.
Figure 4. Patients Completing both PCV13 and PPSV23 Vaccination
Aim
Figure 2. Pneumococcal Vaccine Algorithm for High-Risk Patients with SLE
The aim of this study (Figure 1) was to increase pneumococcal vaccination rates in patients with c-SLE from 3.6% to 50% in 12 months and 80% by 24 months.
Methods
Patients with childhood-onset SLE seen in the pediatric rheumatology clinic at Nationwide Children’s Hospital from January 1, 2015 to August 31, 2016 were included for the baseline analysis. Newly diagnosed patients with c-SLE were included for the ongoing study.
A letter was sent to these patients and their primary care providers requesting an updated immunization record.
An age-based algorithm was developed for pneumococcal conjugate (PCV13) and pneumococcal polysaccharide (PPSV23) vaccination based on current ACIP guidelines (Figure 2), followed by an education session for rheumatology providers and clinic staff
Pre-visit planning included:
Patients were considered to be vaccine compliant if according to age-appropriate recommendations: (1) they received one dose each of PCV13 and PPSV23 and completed the series, or (2) had received at least 1 of pneumococcal vaccines at the visit and were not yet due for the next dose.
Outcomes of interest included percent of patients that have received at least 1 dose of age-appropriate pneumococcal vaccine and percent of patients compliant with vaccine recommendations.
Generating a weekly report of upcoming appointments for c-SLE patients
Entering updated immunization records in the electronic health record (EHR)
Identifying candidates for vaccination and notifying the rheumatology team of vaccination opportunities on a weekly basis
Weekly monitoring by clinic nurses to ensure adequate vaccine stock
Discussion
This study highlights the benefits of pre-visit planning in improving pneumococcal vaccination in patients with c-SLE.
Access to updated immunization records in the EHR at the time of the visit facilitated timely decision making, allowed for targeted vaccine recommendations prior to the visit, minimized the time burden on providers, and served as a reminder to order the vaccine
Future efforts will be directed at building clinical decision support in the EHR for vaccinations in high-risk individuals, evaluating vaccine immunogenicity, and expanding the service to patients with other pediatric rheumatic diseases.
Results
87 patients with c-SLE were seen in the pediatric rheumatology clinic in the study period, with a median age of 18.6 years (range 7-24). At 12 months, 71.3% had updated vaccine records in the EHR, as compared to 25.6% at baseline.
Patients who had received ≥1 dose of age-appropriate pneumococcal vaccine increased significantly from 28.9% at the start of the study to 73.6% at 12 months (p<0.0001) and was sustained for 6 months. Further, 94.1% of c-SLE patients seen in the past month had started the vaccination series (Figure 3).
39% had completed the series with at least 1 dose of PCV13 and 1 dose of PPSV23, compared with 3.6% at baseline (p<0.0001). Among patients seen in the past month, 58.8 % of patients were appropriately immunized per ACIP recommendations, meeting our primary aim (Figure 4).
References
1. Luijten, R.K., et al., Serious infections in systemic lupus erythematosus with a focus on pneumococcal infections. Lupus, (14): p
2. Centers for Disease, C. and Prevention, Use of 13-valent pneumococcal conjugate vaccine and 23-valent pneumococcal polysaccharide vaccine among children aged 6-18 years with immunocompromising conditions: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep, (25): p
3. Heijstek, M.W., et al., EULAR recommendations for vaccination in paediatric patients with rheumatic diseases. Ann Rheum Dis, (10): p
4. Lawson, E.F., et al., Reasons for failure to receive pneumococcal and influenza vaccinations among immunosuppressed patients with systemic lupus erythematosus. Semin Arthritis Rheum, (6): p