Improving Vaccination Rates in Rheumatoid Arthritis

Rheumatoid arthritis and its treatment puts patients at risk for infection, but despite this additional risk, vaccination rates for common diseases are low. According to a review published in Current Opinions in Rheumatology, only about 28.5 percent of patients get the pneumococcal vaccine, 45.8 percent are up-to-date on the influenza vaccine, and a mere 4 percent of those over the age of 60 have received the herpes zoster or shingles vaccine.

Eric Ruderman, M.D., a professor of rheumatology at the Northwestern University Feinberg School of Medicine, is part of a team that has tackled the problem of subpar vaccination rates in their own practice. The group has published on the rates at their clinic and their findings in the American Journal of Managed Care and the Journal of Rheumatology. They found that instituting a comprehensive system of reminders for physicians and patients increased the flu vaccination rate from 60.8 percent to 79.2 percent, the pneumococcal vaccination rate from 28.7 percent to 45.8 percent and the zoster vaccination rate from 2.5 percent to 4.5 percent.  [[{"type":"media","view_mode":"media_crop","fid":"49450","attributes":{"alt":"Eric M. Ruderman, M.D.","class":"media-image media-image-right","id":"media_crop_1717734109449","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5977","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"font-size: 13.008px; line-height: 1.538em; float: right;","title":"Eric M. Ruderman, M.D.","typeof":"foaf:Image"}}]]

Rheumatology Network spoke with Dr. Ruderman to talk about what he learned from trying to improve vaccination rates and how clinicians can apply those lessons in their own practices. This interview has been lightly edited for space.

RN:  What are the issues doctors have to take into consideration regarding vaccines in RA patients?

I think the major issues is how important it is, and I think we lose sight of it. That's one of the reasons we set out on this project. You see patients in the office or the clinic and you're juggling a lot of different things. Clearly, the primary focus is managing their rheumatologic disease, making sure their RA is controlled and responding to therapy and so on. That winds up being much of the visit, which are limited. You don't end up having much time and you lose track of other stuff like comorbidities and vaccinations, which is important because of the risk for infections, many of which can be prevented or at least ameliorated with vaccines.

In many ways, it's not just limited to rheumatology. It's a global problem. Pediatricians spend a tremendous amount of time making sure kids are up-to-date on vaccines, but that's a primary goal of their visit. And in internal medicine, we kind of lose that because there are so many other things going on.

RN:  Is this complicated in rheumatology because of timing vaccinations with treatments?

That's a little of it, but in some ways that can become an excuse, but it doesn't have to be. The fundamental thing you have to remember is there is no issue with vaccinations. There are no safety issues as long as they're not live vaccines. Most of the data suggests that, for the most part, the response to vaccines is at least adequate. The concern has always been that if we're disrupting the immune process with these drugs, are we going to disrupt the ability to respond to these vaccines? And, the answer is largely no.

Probably the most common [concern] would be that rituximab and its impact on B cells may interfere with the magnitude of response, but people still respond and there are still no safety issues.

Live vaccines are an issue and the current CDC recommendations are that live vaccines not be given to patients on biologic therapy or highly immunosuppressant therapy, but that's transplant-level immunosuppression. That's confusing to people because the zoster vaccine right now is a live vaccine and once somebody's on a biologic, they shouldn't get a zoster vaccine. Some published data suggests that it is safe and effective in those patients, but the recommendation says no.

There is some confusion amongst primary care physicians and pharmacists. People go to places like Walgreen's to get their vaccines. I get this from pharmacists who will say, "Well, you're on methotrexate, you can't have zoster vax," which isn't true. The CDC recommendations very clearly states that methotrexate, at doses we use in rheumatology, is not a contraindication. So people get confused.

Biologics can be an issue. In an ideal world, you would give somebody their zoster vaccine while they're on methotrexate, before you get them started on a biologic. The challenge is that zoster vax is approved for patients over 50 but many insurances only cover it over 60. Our RA patients are in their 40s and 50s. So, if I've got somebody who is going to start on biologics, I'd love to give them the zoster vaccine, but their insurance isn't going to cover it and it's $500 or $600 out-of-pocket. That's a real problem.  

RN: What are the reasons that patients might not be up-to-date on vaccines?

There are a couple reasons. One of the things we found very clearly was it's not that they don't want to do it. There's all this noise in the pediatric world about the risks of vaccines, so we thought people would be afraid of vaccines, but that wasn't it at all. The vast majority of patients had no problem recognizing the importance of vaccines. It was that their doctors never mentioned it to them, so they're not coming in to the visit saying, "I need to be vaccinated."

This is all anecdotal, but increasingly people come in to the office in the fall and ask for a flu vaccine because they know they're supposed to. But they don't really come in and ask about pneumococcal vax or zoster. One of the major reasons we found is that physicians didn't bring it up.

Insurance is a lot less of a reason. Insurance will cover pneumo vax. Insurance doesn't cover the zoster vax in younger patients, and that's a problem. The other issue is when a patient's had an episode of zoster but has never been vaccinated, is it appropriate to vaccinate them? The labels don't really account for those patients, but I've talked to the infectious disease docs and they said there's not any reason you can't, but people get confused about that scenario.

Doctors don't mention it because it's just not part of the clinical process. That's sort of a general rheumatology issue. Again, we're focused on managing their rheumatic disease and preventive care isn't high on our list.

RN: So tell me about your intervention to try to improve vaccination rates.

We set out to try to do a number of things at once. First, we added an alert in our electronic medical record to see if patients were up-to-date on their vaccines. It triggers an alert to physicians to remind them. If they look at the alert, it asks them if they vaccinated the patient and if not, do it today. If they chose not to, it asks why.

We also spent some time educating the physicians. And, we tracked physicians and tracked their progress individually and in comparison to the rest of the rheumatologists in our practice. It was not punitive. We didn't shame or share names with everyone else, but it was designed as individual feedback. People want to do the right thing, they just forget.

For the flu vaccine, we sent out reminders to patients prior to the season suggesting they should get their vaccine. We did that either by a letter or for patients who were tapped into the electronic medical records system, we sent an email. Once we got past flu season, we sent reminders to patients for pneumococcal vaccines.

Our PA reached out to patients in search of outside records.That was one of the challenges. People get vaccines in lots of different places: our office, their primary doctor's office, Walgreens, the supermarket or at work. It can be challenging to track those records. Illinois has a state vaccine tracking system which is helpful.

RN:What kind of improvements did you see?

We didn't get tremendous improvement on the flu vaccines but that was because we were doing pretty well to begin with. But, I don’t know that we had the most accurate numbers because people were getting it from different places.

We did improve the pneumo vax rate. More attention is being paid to vaccines in general, so there was some concern about whether the improved rates was due to that attention or our efforts. We compared the rates to one year prior to the project and we saw a shift in the curve. 

For the zoster vaccine, we doubled,  but the absolute numbers were still small. We made some difference, but we didn't see as much as we had hoped to find. 

RN: What did you learn from this experience that you might do differently given the opportunity?

(1) As a physician, it's a hard thing to accept, but you can't rely on physicians. Other papers have looked at this approach to improve routine health maintenance. You can't put all of your eggs in the physician basket. What really seems to make the most difference is the team approach. Bring in the nurses and medical assistants. When they take a patient back to the room and take their vitals, they can look to see if they're up to date with their vaccines. 

A number of places have tried approaches that really carved the physicians out altogether. If the nurse finds out the patient hasn't had a vaccine and there's no reason for not vaccinating, they vaccinate the patient. These are interventions that don't really need physician involvement. So why the extra step? Next time we might build in more autonomy for the nurses.

(2) Another mistake is in thinking that electronic medical records will make it happen, but that's not true. It helps, but if the rest of the system isn't in place, it's not going to make a difference.

The other senior co-author, David Baker, said that electronic medical records can be set up for practice alerts, but they can't make somebody do something they wouldn't otherwise do. 

To make these kinds of interventions work, you have to find something that all physicians know should be done and get their buy-in. You have to train them. A quick and easy fix won't work.

RN: Do you have any final advice for clinicians looking to improve vaccination rates in their practice?

Look at your office, clinic, workflow and staffing. Try to understand how those interactions work and how you can use everybody in the process - not just the physicians. Build a workflow that facilitates getting things done.

References:

Friedman MA, Winthrop K. "Vaccinations for rheumatoid arthritis." 

Current Opinion in Rheumatology

. 2016;28(3):330-336. 

doi:10.1097/bor.0000000000000281

. Sandle, DS, Ruderman EM, Brown T. "Understanding vaccination rates and attitudes among patients with rheumatoid arthritis." 

Am J Manag Care

. 2016;22(3):161-167. 

PMID: 27023021

. Baker DW, Brown T, Lee JY, et al. "A Multifaceted Intervention to Improve Influenza, Pneumococcal, and Herpes Zoster Vaccination among Patients with Rheumatoid Arthritis." 

The Journal of Rheumatology

. 2016. 

doi:10.3899/jrheum.150984

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