SKIN January 2021 Volume 5 Issue 1 Copyright 2021 The National Society for Cutaneous Medicine 25 RISING DERM STARS® ABSTRACTS Preventative Medicine in Dermatologic Care: Providing Immunization Education and Convenient Pneumococcal Immunizations for Patients Receiving Immunosuppressive Therapy Ashleigh Workman, DO1, Josh Lindsley, MS-III2, Nathaniel Webb, MPH3, Thaddeus Miller, DrPH, MPH4, Erica Stockbridge, PhD4, Jean Charles, DO1, Michael Carletti, DO1,2, Stephen Weis, DO1,2,5 1Department of Dermatology, Medical City Weatherford, Weatherford, TX 2Texas College of Osteopathic Medicine, University of North Texas Health Science Center (UNTHSC), Fort Worth, TX 3Department of Biostatistics & Epidemiology, School of Public Health (SPH), UNTHSC, Fort Worth, TX 4Department of Health Behavior & Health Systems, SPH, UNTHSC, Fort Worth, TX 5John Peter Smith Hospital, JPS Health Network, Fort Worth, TX Immunosuppressive therapies increase risk of infections 2-fold when compared to naive individuals;1 however, an observational study found that only 4% of patients with psoriasis who were on or planned to start immunosuppressive therapy were immunized with pneumococcus.2 Factors positively influencing vaccination uptake include having vaccines available same day in clinic and education about vaccines. Negative influences include no recommendation from the treating clinician and no insurance.3 Failure to vaccinate occurs by overlooking indication and an uncertainty as to who is responsible for vaccination.4 Since the early 2000’s, vaccinations have been offered in pharmacies. This could result in additional confusion regarding vaccination responsibility. As a result of not being immunized, patients on immunosuppressive medications experience higher rates of preventable infections. We observed that many of our patients’ immunizations were incomplete and sought to increase immunization uptake through a quality improvement (QI) project beginning in Fall 2019. We evaluated the project’s approach of providing education with immediate onsite immunization availability relative to standard care to determine if vaccination uptake per CDC guidelines5 can be increased. We compared acceptance of CDC recommended pneumococcal immunization for patients on immunosuppressive therapy who were and were not subject to the QI project at the 2 urban dermatology clinics. Patients in the comparison group were under the care of other dermatologists. All patients in the QI group were educated on benefits of immunizations and offered immediate immunizations. Those who had never received the PCV13 or PPSV23 were INTRODUCTION METHODS SKIN January 2021 Volume 5 Issue 1 Copyright 2021 The National Society for Cutaneous Medicine 26 Table 1. Immunization status by group and time point, including unadjusted and adjusted column percentages. N=201. Unadjusted Column Percentages QI Group (N=146) Comparison Group (n=55) p- value Immunization Status Initial observation Final observation Initial observation Final observation No Immunization 69.9 (61.9, 76.8) 13.7 (9.0, 20.4) 60.0 (46.4, 72.2) 60.0 (46.4, 72.2) <0.001 Partially Immunized 18.5 (13.0, 25.7) 47.9 (39.9, 56.1) 32.7 (21.5, 46.3) 32.7 (21.5, 46.3) Fully Immunized 11.6 (7.3, 18.0) 38.4 (30.8, 46.6) 7.3 (2.7, 18.1) 7.3 (2.7, 18.1) Adjusted Column Percentages* QI Group (N=146) Comparison Group (n=55) p- value Immunization Status Initial observation Final observation Initial observation Initial observation No Immunization 66.3 (59.8, 72.7) 16.1 (10.9, 21.3) 62.1 (53.6, 71.6) 62.1 (53.6, 71.6) <0.001 Partially Immunized 26.1 (21.3, 30.9) 43.2 (37.0, 49.4) 28.7 (21.4, 36.0) 28.7 (21.4, 36.0) Fully Immunized 7.7 (3.9, 11.4) 40.6 (0.34, 0.47) 9.2 (5.0, 13.4) 9.2 (5.0, 13.4) *Adjusted column percentages are the average predicted probabilities calculated based on results of a multivariable ordered logit model; probabilities multiplied by 100 and expressed as percentages. defined as unimmunized. Patients who had received either vaccination were partially immunized. Patients who received both were completely immunized. We collected demographics and immunization status for all patients. Using Stata 14.2 [StataCorp, College Station, TX], we compared immunization status at baseline and final observations for patients in the QI and comparison groups using a multivariable ordered logit model, and used multiple logistic regression to examine receipt of a vaccination within the QI group. The QI (N=146) and comparison groups (N=55) did not differ significantly on sociodemographic or clinical characteristics, including baseline immunization. After adjusting for patient characteristics, baseline immunization rates for fully, partially, and unimmunized patients were 9.2%, 28.7%, and 62.1% for the comparison group and 7.7%, 26.1%, and 66.3% for the QI group, respectively. Immunization statuses within the comparison group did not change over time, but at final observation 40.6%, 43.2%, and 16.1% of the QI group were fully, partially, and unimmunized, respectively (Table 1; p<0.001). Of patients in the QI group eligible for vaccination at baseline, 81% (105/129) received a vaccination. There was a significant association between immunization and insurance; uninsured patients in the QI group had significantly lower odds of receiving a vaccination (Table 2; p=0.015). Providing patients on immunosuppressive regimens with education and immediate vaccination access in a dermatology clinic. RESULTS CONCLUSION SKIN January 2021 Volume 5 Issue 1 Copyright 2021 The National Society for Cutaneous Medicine 27 Table 2. Unadjusted and adjusted associations between receipt of one or more pneumonia vaccinations during the QI project and characteristics of persons in the QI group who were not already fully immunized (n=129). Unadjusted Associations Adjusted Associations Variable Total n=129 Column % (95% CI) Vaccine Not Received n=24 Column % (95% CI) Vaccine Received n=105 Column % (95% CI) p-value Odds Ratio (OR) 95% Confidence Interval of OR p-value Gender Female 64.3 (55.6, 72.2) 66.7 (45.4,82.8) 63.8 (54.1, 72.5) 0.792 1.00 (ref) Male 35.7 (27.8, 44.4) 33.3 (17.2, 54.5) 36.2 (27.5, 45.9) 1.06 0.35 3.24 0.917 Age <=34 22.5 (16.0, 30.6) 25.0 (11.4, 46.4) 21.9 (14.9, 31.0) 0.610 1.00 (ref) 35-44 22.5 (16.0, 30.6) 33.3 (17.2, 54.5) 20.0 (13.3, 28.9) 0.81 0.20 3.37 0.777 45-54 19.4 (13.4, 27.2) 12.5 (3.9, 33.2) 21.0 (14.1, 29.9) 3.79 0.56 25.67 0.172 55-64 25.6 (18.7, 33.9) 20.8 (8.7, 42.1) 26.7 (19.0, 36.1) 1.40 0.26 7.64 0.699 >=65 10.1 (5.9, 16.7) 8.3 (2.0, 28.8) 10.5 (5.8, 18.1) 1.06 0.15 7.50 0.955 Primary insurance Private 13.2 (8.3, 20.3) 8.3 (2.0, 28.8) 14.3 (8.7, 22.5) 0.007 1.00 (ref) Public (Medicare or Medicaid) 52.7 (44.0, 61.3) 45.8 (27.0, 65.9) 54.3 (44.6, 63.7) 0.89 0.15 5.22 0.893 County program 24.0 (17.4, 32.3) 16.7 (6.2, 37.7) 25.7 (18.2, 35.0) 1.10 0.15 8.06 0.927 Uninsured 10.1 (5.9, 16.7) 29.2 (14.2, 50.5) 5.7 (2.6, 12.3) 0.07 0.01 0.59 0.015 Patient used translator No 82.9 (75.3, 88.6) 91.7 (71.2, 98.0) 81.0 (72.2, 87.4) 0.208 1.00 (ref) Yes 17.1 (11.4, 24.7) 8.3 (2.0, 28.8) 19.0 (12.6, 27.8) 7.14 0.91 56.31 0.062 Count of prior office-based contacts (all provider specialties) 0-3 visits 30.2 (22.8, 38.8) 33.3 (17.2, 54.5) 29.5 (21.5, 39.1) 0.89 1.00 (ref) SKIN January 2021 Volume 5 Issue 1 Copyright 2021 The National Society for Cutaneous Medicine 28 4-8 visits 29.5 (22.2, 38.0) 33.3 (17.2, 54.5) 28.6 (20.7, 38.1) 0.62 0.17 2.28 0.473 9-14 visits 26.4 (19.4, 34.7) 20.8 (8.7, 42.1) 27.6 (19.8, 37.1) 0.85 0.20 3.68 0.829 >=15 visits 14.0 (8.9, 21.2) 12.5 (3.9, 33.2) 14.3 (8.7, 22.5) 0.74 0.14 3.82 0.717 Visit type at initial observation Initial 20.2 (14.0, 28.1) 25.0 (11.4, 46.4) 19.0 (12.6, 27.8) 0.512 1.00 (ref) Follow-up 79.8 (71.9, 86.0) 75.0 (53.6, 88.6) 81.0 (72.2, 87.4) 1.98 0.52 7.51 0.317 Number of indications other than medication(s) and age† Count Variable‡ 0.81 (0.64, 0.97) 0.75 (0.35, 1.14) 0.82 (0.64, 1.00) 0.746 0.98 0.50 1.91 0.952 Immunosuppresive medications used prior to initial observation No 16.3 (10.8, 23.8) 12.5 (3.9, 33.2) 17.1 (11.0, 25.7) 0.578 1.00 (ref) Yes 83.7 (76.2, 89.2) 87.5 (66.8, 96.1) 82.9 (74.3, 89.0) 0.40 0.08 2.06 0.271 † Includes heart disease (congestive heart failure or coronary artery disease), diabetes, lung disease (chronic obstructive pulmonary disease or asthma), chronic renal failure, or being a current smoker. Possible range 0-5, actual range 0-4. ‡ Unadjusted numbers represent mean significantly increased uptake of recommended pneumococcal immunization. Widespread use of this practice could reduce vaccine preventable illness and improve population health. Furthermore, there is a clear need for additional interventions targeting uninsured patients. Conflict of Interest Disclosures: None Funding: None Corresponding Author: Dr. Stephen Weis, D.O. Health Science Center Medical City Weatherford Department of Dermatology 1301 Throckmorton Street Unit 1803 Fort Worth, Texas Email: Stephen.Weis@unthsc.edu References: 1. R Gluck, T. and U. Muller-Ladner (2008). "Vaccination in patients with chronic rheumatic or autoimmune diseases." Clin Infect Dis 46(9): 1459-1465. 2. Bonhomme, A., et al. (2017). "[Vaccination status in psoriasis patients on immunosuppressant therapy (including biologics)]." Ann Dermatol Venereol 144(2): 92-99. 3. Bacurau AGM, Francisco PMSB. Reasons for non-vaccination against influenza among older adults with hypertension in Brazil: a cross- sectional study. Sao Paulo Med J. 2020;138(4):322-325. doi:10.1590/1516- 3180.2020.0042.r1.15052020 4. Lejri-El Euchi, H., et al. (2019). "Vaccination against influenza and pneumococcal infections in patients with autoimmune disorders under biological therapy: Coverage and attitudes in patients and physicians." Eur J Intern Med. 5. Rubin, L. G., et al. (2014). "2013 IDSA clinical practice guideline for vaccination of the immunocompromised host." Clin Infect Dis 58(3): 309-318. mailto:Stephen.Weis@unthsc.edu