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Abstract

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Objective

To examine whether an electronic health record (EHR) best practice alert (BPA), a clinical reminder to help guideline adherence, improved vaccination rates in rheumatology patients receiving immunosuppressants. Guidelines recommend yearly influenza and pneumococcal vaccination with revaccination for patients age >65 years who are taking immunosuppressive medications.

Methods

A vaccination BPA was developed based on immunosuppressant treatment, age, and prior vaccinations. At site 1, a hospital-based academic practice, physicians ordered vaccinations. At site 2, a community-based practice, physicians signed orders placed by nurses. Demographics, vaccination rates, and documentation (vaccination or no administration) were obtained. Chi-square and Fisher's exact test analysis compared vaccination and documentation rates for October 1 through December 31, 2006 (preBPA), and October 1 through December 31, 2007 (postBPA). Breslow-Day statistics tested the odds ratio of improvement across the years between the sites.

Results

PostBPA influenza vaccination rates significantly increased (47% to 65%; P < 0.001), with significant improvement at both sites. PostBPA pneumococcal vaccination rates likewise significantly increased (19% to 41%; P < 0.001). PostBPA documentation rates for influenza and pneumococcal vaccinations also increased significantly. Site 2 (nurse-driven) had significantly higher preBPA vaccination rates for influenza (69% versus 43%; P < 0.001) than pneumococcal (47% versus 15%; P < 0.001).

Conclusion

The use of a BPA significantly increased influenza and pneumococcal vaccination and documentation rates in rheumatology patients taking immunosuppressants. A nurse-driven process offered higher efficacy. An EHR programmed to alert providers is an effective tool for improving quality of care for patients receiving immunosuppressants.


INTRODUCTION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

Rheumatology patients are often immunocompromised by both their diseases and by their medications (1–11). Although vaccine efficacy may decrease in some disease states, guidelines recommend influenza and pneumococcal vaccination for immunocompromised patients (12–15). Our rheumatology department sought to improve vaccination rates in patients who take immunosuppressive medications.

Influenza vaccination can prevent up to 70% of influenza infections in adults, improve mortality of patients who develop community acquired pneumonia, and decrease overall mortality in the elderly by up to 48% (16–18). Pneumococcal vaccination prevents infection, is cost effective, and reduces risk of pneumococcal bacteremia (19–21).

Rheumatoid arthritis (RA) patients experience higher rates of respiratory infections, with pneumonia being an established cause of mortality (1–5). Infections in systemic lupus erythematosus (SLE) patients account for 20–55% of all SLE-related deaths (1–7). Infection is also a leading cause of death in patients with multiple vasculitides (6).

Methotrexate (MTX), tumor necrosis factor α (TNFα) inhibitors, cytotoxic therapy, and other immunosuppressive drugs are all associated with increased infection risk (8–11). Infection with MTX therapy most often occurs within the first year of treatment, but infection frequency is not related to treatment duration (8, 9). RA patients taking TNFα inhibitors have an increased risk of serious infections (10), and patients receiving cytotoxic therapy are prone to infections from lymphopenia (6).

Safety data for vaccination in rheumatology patient populations dates back to 1978. A prospective study done in patients with active SLE showed influenza vaccination did not increase disease activity (22–26). Pneumococcal vaccination has also been demonstrated to be safe in SLE and RA patients (27).

Influenza vaccine efficacy may be decreased by certain diseases and medications. Influenza response rates are slightly lower among RA patients, although they still generated a response that did not appear affected by prednisone and immunosuppressive drugs (28). Humoral and cell-mediated responses to influenza vaccination may be diminished in patients with SLE (7, 25), and SLE patients taking azathioprine may have a decreased immune response (24).

MTX impairs the immune system's response to pneumococcal antigen in RA patients, but anti-TNF agents do not (29). RA patients receiving rituximab may not be sufficiently protected by an influenza vaccination (30). Psoriatic arthritis patients treated with etanercept produced antibodies to pneumococcal antigen, but patients with concomitant MTX treatment had lower levels (31). Severely immunosuppressed patients can still mount a response of up to 77% protective efficacy, although this may be decreased in some patients with RA and SLE (27, 32, 33).

The Advisory Committee on Immunization Practices (ACIP) provides yearly recommendations for adult immunizations. The guidelines state that influenza and pneumococcal vaccines should be administered to immunocompromised patients, including those whose immune systems are weakened by their medications (12, 13). The Centers for Disease Control and Prevention (CDC) compiled a list of immunosuppressive medications that includes high-dose corticosteroids (>20 mg/day), alkylating agents (cyclophosphamide), antimetabolites (azathioprine, 6-mercaptopurine), transplant-related immunosuppressive drugs (cyclosporine, tacrolimus, sirolimus, and mycophenolate mofetil), MTX, and mitoxantrone (11). The recommendations from the American College of Rheumatology (ACR) advise influenza vaccination for all patients prior to starting hydroxychloroquine, leflunomide, MTX, minocycline, sulfasalazine, and all biologic agents (14). These ACR recommendations also state patients should receive pneumococcal vaccination prior to starting leflunomide, MTX, sulfasalazine, and all biologic agents.

Unfortunately, a significant care gap exists between vaccination awareness and actual vaccination rates. According to the CDC data for 2006, only 64% of noninstitutionalized adults age 65 years and 30% of younger high-risk adults were vaccinated for influenza, and only 57% and 17%, respectively, were vaccinated for pneumonia (34). Rheumatology patients often have lower influenza and pneumococcal vaccination rates compared with the general population, and raising patient awareness does not necessarily improve vaccination rates (35–38).

One of the most important physician barriers to pneumococcal vaccination is physician oversight. Clinical reminders, both in electronic health records (EHRs) and paper charts, improve vaccination coverage (39, 40). Other measures to improve vaccination rates include performance measurements programs, continuing education for health care providers, standing orders, vaccination outside of physician offices, decreased cost by bulk billing, and nurse-led immunization (36–48).

Geisinger Health System, designated among most wired institutions in the US, employs a system-wide electronic medical record (49). We sought to utilize the advantages the EHR offers to improve vaccination rates in our patients, who experience a wide variety of rheumatic diseases including but not limited to RA, psoriatic arthritis, spondylarthropathies, vasculitides, inflammatory myopathies, and connective tissue diseases. The rheumatology department worked in conjunction with the Geisinger Health System's best practice team to devise an electronic clinical reminder, a best practice alert (BPA), which notifies health care providers when patients taking immunosuppressive drugs need influenza and pneumococcal vaccinations. The health care provider then has the opportunity to educate the patient on the benefits of vaccination and offer the necessary vaccine(s). The BPA provides a predefined set of orders to administer the vaccine or the opportunity to document the reason for no administration (i.e., patient refusal, contraindication, or vaccinated elsewhere).

The rheumatology BPA was utilized in 2 different clinical settings. Site 1 was an academic institution with a 4:1 ratio of health care provider to nurse. A health care provider was defined as an attending physician, fellow, resident, or nurse practitioner. Site 2 was a community practice setting with a 1:1 rheumatologist to nurse ratio. Site 2 nurses also participate in a system-wide community practice service line that manages an influenza and pneumococcal outreach program. The community practice service line nurses received incentives for vaccinating patients with diabetes mellitus and, as part of a home medical model, were prompted to vaccinate all patients age 18 years for influenza if supplies permitted. They also measured vaccination progress. They were familiar with BPAs customized for patients in other high-risk groups and utilized a written protocol to administer influenza and/or pneumococcal vaccines to appropriate patients without a physician's order.

PATIENTS AND METHODS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

BPA development.

Geisinger Health System's EHR utilizes health maintenance reminders to improve standardization of recommended preventive screenings, such as colonoscopies and mammograms. These maintenance reminders require the physician to click a reminder tab, review recommended tests, and then place orders. A BPA expands upon health maintenance reminders in a more engaging process. When the patient is seen in the clinic, the BPA appears prominently onscreen as a clinical reminder with an attached order set. Since the alert actively addresses vaccination status, it offers providers the opportunity to document why a vaccination was not given (i.e., patient refusal, contraindication, or the vaccine was given elsewhere).

The influenza BPA signals physicians to administer an influenza vaccination when an adult patient is taking a listed immunosuppressive drug and is seen in the office during influenza season (defined as October 1 through February 28). The pneumococcal BPA signals physicians to administer a pneumococcal vaccination when an adult patient is receiving an immunosuppressive drug and lacks documentation of a prior vaccination if age <65 years, or within the past 5 years if age ≥65 years. The immunosuppressive drugs included in the initial BPA were MTX, etanercept, adalimumab, infliximab, abatacept, leflunomide, rituximab, azathioprine, anakinra, mycophenolate mofetil, cyclophosphamide, and prednisone.

BPA implementation.

The influenza BPA fired if the patient was age ≥18 years, receiving a listed immunosuppressive drug, had never received an influenza vaccination, and the current date was between October 1, 2007 and February 28, 2008.

The pneumococcal BPA fired if the patient was age ≥18 years (age <65 years), receiving a listed immunosuppressive drug, and had never received a pneumococcal vaccination (or the patient was age ≥65 years and last pneumococcal vaccination date was >5 years prior).

At site 1, the process was as follows: the patient is seen in the rheumatology clinic, the EHR is opened, the BPA fires according to the logic stated (influenza, pneumococcal, or both), the health care provider discusses the vaccination with the patient, and then either orders the vaccination or documents no vaccination or vaccination elsewhere. A nurse then administers a vaccination if ordered.

A vaccination order requires the health care provider to click “accept” when the BPA appears, check the order box, and sign the order. Documenting no vaccination entails a 5-step process: the provider clicks on a toolbar to the left of the BPA, then clicks a tab for “new administration,” searches a drop-down bar for the vaccination, then chooses either a defer tab or a given tab. If the defer tab is selected, the provider then chooses the reason: contraindication, clinical disease, or patient refusal. If the given tab is chosen, the provider types in the date and location of the vaccination. The option of additional documentation under a comments tab is also available for both the given and defer tabs.

At site 2, the process was as follows: the patient is seen in the rheumatology clinic, the EHR is opened, the BPA fires according to the logic statement, the nurse discusses the vaccination with the patient, accepts the BPA, and checks the order. The physician signs the order and the nurse administers the vaccination. Documenting no vaccination or vaccination elsewhere required the nurse or the physician to pursue the same 5-step process outlined for site 1.

Data acquisition.

An electronic data pull was performed. Data were collected for the time period of October 1, 2006 through December 31, 2006 (preBPA), and October 1, 2007 through December 31, 2007 (postBPA). Inclusion criteria for the 2 time periods were identical to those programmed into the BPA.

For the influenza vaccination, inclusion criteria were defined as rheumatology patients taking a listed immunosuppressive drug, seen in the office during influenza season (October 1 through February 28), and age ≥18 years. For the pneumococcal vaccination, inclusion criteria were rheumatology patients taking an immunosuppressive drug, age ≥18 years, and lack of documentation of a prior vaccination within the past 5 years if age ≥65 years.

Prednisone was not included as a criterion in the data pull. Prednisone is considered an immunosuppressive drug at >20 mg/day (11). However, programmers could not develop a feasible electronic method to identify exact prednisone dosage and chronicity. Patients taking immunosuppressants but who were not seen in the designated time period of October 1 through December 31, 2006 or 2007 were not counted in the analysis.

A retrospective chart review was then performed on the collected data in the preBPA time period. Charts lacking orders for influenza and/or pneumococcal vaccination were reviewed for documentation of vaccination (at a site other than Geisinger Health System), patient refusal, or contraindication.

Statistical analysis.

The total influenza vaccination data set consisted of 777 unique vaccine-eligible patients in 2006, and 758 unique vaccine-eligible patients in 2007; combined there were 1,535 flu vaccination possibilities but 1,082 unique patients (453 patients were vaccination possibilities in both years). The 2 groups from different years were treated as separate vaccine-eligible groups and were not analyzed at the unique patient level (correlations within patients were not accounted for).

The total pneumococcal data set consisted of 516 unique vaccine-eligible patients in 2006 and 426 unique vaccine-eligible patients in 2007; combined there were 942 pneumococcal vaccination possibilities, but 738 unique patients (204 patients were in both years). The 2 groups from different years were treated as separate vaccine-eligible groups and were not analyzed at the unique patient level (correlations with patients were not accounted for). There were fewer patients in the pneumococcal data set because of the additional logic statement in the pneumococcal BPA that excluded patients with a prior vaccination within the previous 5 years.

Differences in preBPA and postBPA demographics of age, race, and sex were first compared with Wilcoxon's analysis (median age) and chi-square test (sex), or Fisher's exact tests (race). Differences in preBPA and postBPA documentation and vaccination rates were compared at each site also using the chi-square test. The Breslow-Day statistic was used to test the difference between rates preBPA and postBPA between the 2 sites. A P value of less than or equal to 0.05 was considered statistically significant.

RESULTS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

For preBPA and postBPA implementation, patient demographics were similar in sex, race, and age at both sites. (Table 1). Seventy percent of the patients were women. Wilcoxon's test did not show a significant difference of the medians.

Table 1. Patient demographics*
 2006, preBPA2007, postBPA
  • *

    Values are the percentage unless otherwise indicated. BPA = best practice alert; IQR = interquartile range.

Sex  
 Male3031
 Female7069
White9797
Age, median (IQR)59 (48–68)58 (49–69)

There were 777 influenza vaccine–eligible patients observed at both sites prior to the influenza BPA implementation, and 758 influenza vaccine–eligible patients observed after. Influenza vaccination rates increased from 47% to 65% (P < 0.001) at both sites, and influenza documentation rates increased from 47% to 67% (P < 0.001) (Figures 1A and B). There were 516 pneumococcal vaccine–eligible patients observed at both sites prior to the pneumococcal BPA implementation and 426 pneumococcal vaccine–eligible patients observed after. Pneumococcal vaccination rates increased from 19% to 41% (P < 0.001) at both sites, and pneumococcal documentation rates increased from 19% to 45% (P < 0.001) (Figures 1C and D). At site 1 (academic institution using a provider-driven process), influenza vaccination rates increased from 43% to 60% (P < 0.001). Influenza documentation rates increased from 43% to 62% (P < 0.001). Pneumococcal vaccination rates increased from 15% to 39% (P < 0.001), and pneumococcal documentation rates increased from 15% to 42% (P < 0.001).

thumbnail image

Figure 1. A, Influenza vaccination rates, and B, documentation rates pre- and postBPA implementation for the entire populations and by site. C, Pneumococcal vaccination rates and D, documentation rates pre- and postBPA implementation for the entire populations and by site. BPA = best practice alert.

Download figure to PowerPoint

At site 2, (community practice setting with a nurse-driven process and prior familiarity with health maintenance reminders and BPAs), the influenza vaccination rate increased from 69% to 82% (P = 0.014). The influenza documentation rate increased from 69% to 86% (P = 0.001). Pneumococcal vaccination rates increased from 47% to 57% (P = 0.31), and pneumococcal documentation rates increased from 47% to 73% (P = 0.008).

At baseline, site 2 had significantly higher vaccination rates compared with site 1 prior to BPA implementation. PreBPA influenza vaccination rates for sites 2 and 1 were 69% versus 43% (P < 0.001). PreBPA pneumococcal vaccination rates for sites 2 and 1 were 47% versus 15% (P < 0.001). After BPA implementation, site 2 also had significantly higher influenza vaccination rates at 82% versus 60% (P < 0.001). PostBPA pneumococcal vaccination rates at site 2 were likewise higher at 57% versus 39% (P = 0.025).

DISCUSSION

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

This study demonstrated that a BPA electronic clinical reminder improved influenza and pneumococcal vaccination of rheumatology patients taking immunosuppressive medications in both academic- and community-based practices. The BPA also improved documentation of vaccinations given outside the health system and documentation of patient refusal or contraindication.

Site 2 (community-based) experienced higher vaccination and documentation rates for both influenza and pneumococcal vaccinations. Unfortunately, the study design does not include separate data for all the different combination of factors, so it is not possible to determine which combination(s) or factor(s) contributed more to the site differences. However, there are several plausible factors that contributed to the higher rates at site 2. At site 1 (academic-based), the onus of responding to the BPA was assigned to physicians (staff, fellows, and residents) burdened by addressing multiple medical issues. At site 2, nurses responded to the BPA as part of the check-in process when they obtained patient vital signs and medications. These nurses were already familiar with the BPA, and were already employed in other programs with incentives. In addition, they were familiar with educating patients on the benefits of vaccination, administering the vaccine, and documenting vaccination or no vaccination. Finally, site 2 also had more available nursing personnel to assist with the BPA. Therefore, site 2 had a nurse-driven BPA process, nurses who were incentivized to work the BPAs, and proportionately more nurses. This nurse-based model (where the nurse accepts the BPA as part of the check-in process, marks the order that the physician only has to sign, and then administers the vaccination) has since been adopted at site 1 and is being implemented at a third Geisinger Health System rheumatology site.

Although site 1 achieved a greater increase in influenza and pneumococcal rates comparing preBPA with postBPA, site 2 had higher actual vaccination rates both preBPA and postBPA. Ultimately, it is the actual rate achieved, not the increase that defines the most successful flow (i.e., it is better to have a final vaccination rate increase from 69% to 82%, then an increase from 43% to 60%, even though the latter is a greater increase). As mentioned above, the nurse-driven model at site 2 exhibited both higher baseline and final achieved rates compared with a physician-driven model. The smaller relative increase in site 2 compared with site 1 may have to do with a ceiling effect, i.e., at vaccination rates of >80% in complicated immunosuppressed patients, getting the last 20% vaccinated may be the most difficult.

Site 2 did not experience a significant increase in pneumococcal vaccination rates. This probably occurred because the baseline vaccination rate was higher preBPA, making it close to whatever is the likely highest achievable vaccination rate. At both sites, pneumococcal vaccination rates were lower then influenza. This may be secondary to the lack of patient awareness regarding the importance of pneumococcal vaccination. The general public may be more aware of the benefits of the influenza vaccination. Therefore, health care providers must exert more time and effort to discuss the benefits of pneumococcal vaccination with patients.

Documentation rates remained below 65%, despite improvement with the BPA. A plausible explanation for the low documentation rates may be the cumbersome 5-step process. Busy practitioners may overlook these additional steps. While knowledge of the specific reasons why patients declined vaccination would be of interest, the current EHR only allows for a drop-down list choice of contraindication, clinical disease, or refused. Obtaining a higher level of refusal detail would require additional typing and would not be searchable information.

A potential limitation of this study is that prednisone was excluded from the data analysis. Prednisone is considered an immunosuppressive drug at a dosage of >20 mg/day (11). However, programmers could not determine prednisone dosing for the data pull. Another potential limitation is that the BPA system is based on clinic visits. Patients who miss office visits or who are not scheduled during the influenza season will miss the opportunity for vaccination through the BPA. This is an inherent limitation of all BPAs, which are designed around point-of-service care. A proactive data pull would be needed to identify patients requiring vaccination. Those who have not been seen would need to be contacted by letter or phone and subsequently scheduled. Our previous experience has shown that this approach, while logical, only results in 40% of at-risk patients receiving care. This approach has a significant administrative burden and cost when compared with a BPA (50).

The BPA has been modified to include the updated recommendations from the ACR 2008 recommendations (14). The updated influenza alert now includes hydroxychloroquine, minocycline, and sulfasalzine as alert triggers, and the pneumococcal alert now includes sulfasalazine. The ACIP 2009 recommendations have been reviewed and the BPA is still consistent with the recommendations (13).

A BPA significantly improved the quality of care delivered in both academic and community rheumatology practice settings by improving vaccination rates for influenza and pneumococcal pneumonia according to national recommendations. A nurse-driven process was associated with higher vaccination and documentation rates, as were prior familiarity with patient education and BPAs.

AUTHOR CONTRIBUTIONS

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES

All authors were involved in drafting the article or revising it critically for important intellectual content, and all authors approved the final version to be submitted for publication. Dr. Harrington had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study conception and design. Ledwich, Harrington, Ayoub, Newman.

Acquisition of data. Ledwich, Ayoub, Newman.

Analysis and interpretation of data. Ledwich, Harrington, Ayoub, Sartorius, Newman.

REFERENCES

  1. Top of page
  2. Abstract
  3. INTRODUCTION
  4. PATIENTS AND METHODS
  5. RESULTS
  6. DISCUSSION
  7. AUTHOR CONTRIBUTIONS
  8. REFERENCES
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