Herpes Zoster Vaccine Rates Improved with Electronic Vaccine Tracking System

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Patients with rheumatoid arthritis are often not appropriately vaccinated against herpes zoster, despite vaccine recommendations.
Patients with rheumatoid arthritis are often not appropriately vaccinated against herpes zoster, despite vaccine recommendations.

Electronic notification of patient's vaccine eligibility improved herpes zoster vaccine rates among patients with rheumatoid arthritis (RA) without modifying physician's workflows, according to research published in the Journal of Rheumatology.1

Rohit Aggarwal, MD, MS, professor of medicine, Division of Rheumatology and Clinical Immunology in the Department of Medicine at the University of Pittsburgh, and colleagues oversaw a herpes zoster vaccination improvement project—a continuous quality improvement project—designed to determine the effect of the project on herpes zoster vaccination rates among patients with RA.

The goal of the project was to develop a decision support system that incorporated best practice alerts in outpatient electronic medical records (EMRs); modifying the clinic workflow to most effectively process best practice alerts; educating clinicians, practice staff, and patients on current vaccine recommendations for immunosuppressed patients; and incorporating physician feedback and interval assessment to improve the process.

Eligible patients were aged ≥60 years, were prescribed any oral disease modifying antirheutmatic drug (DMARD, methotrexate [MTX], leflunomide, sulfasalazine, or minocycline) or corticosteroid (10 mg equivalent of prednisone > 3 months), or if they were going to be treated with a biologic or small molecule drug (anakinra, abatacept, etanercept, inflixmab, adalimumab, certolizumab, golimumab, rituximab, tocilizumab, or tofacitinib).

Between July 2012 and June 2013 (pre-intervention) and February 2014 and January 2015 (post-intervention), 1823 and 1554 patients, respectively, were evaluated. In the pre-intervention period, herpes zoster vaccination rates and documentation rates were 10.1% and 28%, respectively. During the intervention phase, vaccination rates improved significantly, increasing to 51.7%, (P <.0001) and documentation rates increased to 72.9% (P <.0001). 

The best practice alert appeared 1299 times for the 1002 eligible patients without prior vaccination or documentation, occurring for 279 patients at 2 visits during the intervention period. Among these patients, 43% were vaccinated and 4% had the vaccine prescribed; 53% had documentation of reasons why the vaccine was not prescribed (73% refused the vaccination, 27% were deferred for medical reasons).

Researchers surveyed 31 physicians to assess the efficiency of the best practice alert system, with a 45% response rate. Seventy-four percent of physicians liked the best practice alert process, and felt that vaccines were easy to order using the system; 80% of physicians felt that the system improved patient care.

During the intervention period, all physicians and clinics improved their vaccination and documentation rates; 36 patients (2%) had developed herpes zoster infections during the pre-intervention phase, compared to 5 patients (0.32%) during the post-intervention phase (P =.002).

“Rheumatologists commonly focus on rheumatic disease management, leaving preventive care to primary care providers,” the researchers noted. “However, [herpes zoster] vaccination rates in some primary care practices may also be suboptimal.”

“Electronic [best practice alerts] and an ancillary staff-based protocol in rheumatology improved [herpes zoster] vaccination rates. The process is innovative, generalizable, and sustainable,” the researchers concluded. 

Study Limitations

  • The project was supported by a research coordinator who served as a point person for concerns and queries, which may have increased compliance
  • Insurance concerns may have influenced vaccination compliance 

Reference

  1. Sheth H, Moreland L, Peterson H, Aggarwal R. Improvement in herpes zoster vaccination in patients with rheumatoid arthritis: a quality improvement project. J Rheum. 2016; doi: 10.3899/jrheum.160179
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