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ORIGINAL RESEARCH
The Effect of Offering Pneumococcal Vaccines During Specialty
Care on Vaccination Rates in Patients Receiving
Immunosuppressive Therapy
Joshua Lindsley1, Nathaniel Webb, MPH2, Ashleigh Workman, DO3, Thaddeus Miller, DrPH,
MPH2, Erica Stockbridge, PhD1, Jean Charles, DO3, Michael Carletti, DO1,3, Stephanie
Casperson RN, BSN, 4, Stephen Weis, DO1,3,4
1Texas College of Osteopathic Medicine, University of North Texas Health Science Center, Fort Worth, TX
2Department of Health Behavior & Health Systems, School of Public Health, University of North Texas Health
Science Center, Fort Worth, TX
3Department of Dermatology, Medical City Weatherford, Weatherford, TX
4John Peter Smith Hospital, JPS Health Network, Fort Worth, TX
ABSTRACT
Purpose: To determine whether clinician-led immunization education with immediate onsite vaccination
availability will increase pneumococcal immunizations during specialty care.
Methods: We used a controlled before and after quasi-experimental design to retrospectively evaluate
quality improvement (QI) project effectiveness. The project included two clinics. Clinic #1 was a part of the
county hospital system and offered comprehensive care. Clinic #2 was a university clinic that hosted a
private practice and a dermatology resident continuity clinic. Resident continuity clinics are structured to
enable residents to develop longitudinal relationships with patients with skin disease. Patients within each
of these clinics were subject to the intervention or usual care based on their treating physician. The
intervention included clinician-provided verbal immunization recommendations, dialogue exploring and
addressing patients’ immunization concerns, and immediate availability of vaccine and administration. The
main measure of outcome was pneumococcal immunization status after QI intervention.
Results: Our analysis included 201 patients with planned or existing immunosuppressive medication
regimens attending an initial or follow-up dermatology visit (aged 0-64 years [82.1%], aged ≥65 years
[17.9%]; male [34.3%], female [65.6%%]). Of these, 146 [72.6%] were in the QI group and 55 [27.4%] in
the comparison group. While we identified no significant QI/comparison group differences in immunization
status at initial observation (p=0.329), immunization status differed significantly by group at the final
observation (p<0.001). The QI group had a significant increase in immunization status compared to the
comparison group (p<0.001). Overall, 81.4% (95% CI: 73.6, 87.3) of patients in the QI group without full
immunization at initial observation received at least one vaccination by the final observation, while we
observed no change in immunization status for the comparison group from initial to final observation.
Conclusion: These data demonstrate that immunization coverage in patients on immunosuppressive
medications can be markedly improved by clinician recommendation with immediate availability of the
pneumococcal vaccine during specialty care. Wider adoption of this model and its adaptation to other
immunizations and settings is an important opportunity to reduce vaccine-preventable illness, including
COVID-19, and improve population health.
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Morbidity and mortality from vaccine-
preventable illnesses are higher among
patients on immunosuppressive treatment.1-
7 Immunosuppressive therapies increase the
risk of infections by at least 2-fold compared
to non-immunosuppressed individuals.6,8
The incidence rate of invasive
pneumococcal disease is approximately 6-
fold higher in patients with chronic
inflammatory disease receiving
immunosuppressive medications when
compared to healthy individuals.9 Patients
receiving immunosuppressive medications
are recommended to receive routine
pneumococcal immunizations to reduce
infectious complications.10,11 These
recommendations are not completely
implemented worldwide. Studies conducted
around the world find that persons on
immunosuppressive medications and
persons with chronic conditions commonly
treated with such medications are
undervaccinated, with pneumococcal
vaccination rates ranging from 0% in
Morocco to 56.5% in France.12-15 More
effectively addressing this disparity is key to
reducing morbidity, mortality, and economic
losses from vaccine-preventable disease.
6,12,16,17
There are many reasons vaccination
coverage is low in adult and
immunosuppressed populations.18-20 Most
immunosuppressed patients cited lack of
physician recommendation for the reason for
their being unimmunized.18,21,22 Other
concerns include vaccine safety and
efficacy.20 The most common reason cited
by physicians for not immunizing was
forgetting to recommend.19,20 Another
clinician barrier to immunizing is uncertainty
of vaccination schedule.18 In addition to
patient and clinician barriers there are
system immunization barriers including
fragmented delivery systems, uneven
access, and lack of immunization
coordination. Vaccination is widely available
from pharmacies, urgent care, primary care,
specialty, and public health clinics. There is
no system for routine communication
between these sites providing
immunizations and an adult vaccine registry.
This can lead to both patient and clinician
uncertainty as to an individual’s vaccine
status. Often as a result of this uncertainty, a
patient leaves the office without
immunization but with plans for future
immunization.
Recommendations for where vaccination
should occur are either absent or it is
recommended that they be given by a
primary care clinician.23-25 General
practitioners surveyed about who should
provide immunizations for patients on
immunosuppressive medications believed
the prescribing specialist should monitor the
immunizations.26 Surveys of Irish
rheumatologists showed 57% thought
general practitioners should be responsible
for providing these patients with
immunizations.27 These data illustrate there
is discordance about who should ultimately
be responsible for vaccinating
immunosuppressed patients.
The CDC Advisory Committee on
Immunization Practices (ACIP) has
recommended several strategies to increase
vaccine adherence.28 Useful methods
include direct patient communications and
organizational changes such as separate
clinics devoted to prevention, planned
preventive medicine visits, or the use of non-
physician staff to do preventative medicine
visits.29,30 Absent or weak immunization
recommendations from clinicians are a
primary cause of low immunization uptake.31
INTRODUCTION
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Similar to other organizations, our
dermatology practice observed low
pneumococcal immunization coverage
among patients receiving
immunosuppressive care. The ACIP states
that the two most important predictors of
immunization acceptance among adults are
the healthcare provider’s recommendation
and availability of the vaccine during the
same visit.32 We designed a quality
improvement (QI) project around this logic,
hypothesizing that clinician-led immunization
education with immediate onsite vaccination
availability will increase receipt of
pneumococcal immunizations during
specialty care. We evaluated the results of
the QI project and present our findings in
this report.
This project was approved as exempt
category research by the North Texas
Regional Institutional Review Board.
Study Design and Participants
We used a before and after quasi-
experimental design to retrospectively
evaluate our QI project to increase
acceptance of pneumococcal immunizations
in immunosuppressed patients33. Our
evaluation included all patients who were
newly or previously prescribed chronic
systemic immunosuppressive therapy that
visited any of four dermatology practices
during a defined period. Therapies of
interest included biologics, antimetabolites,
oral corticosteroids, and other
immunosuppressive medications.
The four dermatology practices were in two
clinics; one dermatology practice in each
clinic administered the QI intervention while
the other practice provided standard care.
Patients were subject to the intervention or
usual care based on their treating physician
(eMethods). All eligible patients seeking
care between September (Clinic #1) or
November (Clinic # 2) of 2019 through
March 30, 2020 were included in analyses.
All were followed for immunization
completion through July 2020.
Both clinics provide care to patients of
predominately lower socioeconomic status
in Tarrant County, Texas. In 2019, Tarrant
County’s estimated population was
2,102,515 residents across its 863.6 square
miles; 51.8% of whom were white, 26.7%
Hispanic or Latino, 14.5% Black or African
American, 4.6% Asian, and 2.4% other 34.
Standard Care
Prior to the QI intervention, PVC13 and
PPSV23 pneumococcal vaccine was on the
formulary of both institutions and clinic staff
were familiar with vaccine administration
and EMR documentation. However,
dermatologists recommended that
immunosuppressed patients see their
primary clinicians to update pneumococcal
vaccinations.
Quality Improvement Intervention
As a QI intervention, the physician provided
each eligible patient with immunization
recommendations based on their
immunization status and ACIP guidelines.
Educational elements included the
increased risk of infection associated with
immunosuppressive medications, benefits of
immunization to reduce this risk, and
addressing any concerns the patients had
about the vaccine28. Patients were given an
opportunity to receive pneumococcal
immunizations immediately after the
physician education.
Data Source and Measures
Data for all variables were retrospectively
collected from electronic medical records
METHODS
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(EMR). Patients were also queried about
immunizations received from outside the
practice, either during routine visits or in
follow-up telephone calls.
The primary outcome measure was
immunization status. We created a three-
level ordinal immunization status variable
based on ACIP guidelines28, categorizing
patients as having no, partial, or full
immunization. Immunization status was
evaluated at two points in time: 1) the first
visit to the dermatology clinic during the
project period (initial observation), and 2) the
end of the observation period (final
observation). Data from the two clinics were
combined for analysis, so patients were in
one of two groups: 1) the QI group, or 2) the
comparison group. Thus, time and group
were variables in our analyses.
Analyses included demographic, care
delivery, and patient health variables.
Demographic variables included gender,
age, race/ethnicity. The care delivery
variables included insurance status, use of
translators, and past-year office-based
healthcare visits to any clinician. Patient
health variables included the number of
comorbid conditions, the condition for which
immunosuppressive medications were
prescribed, the number and types of
immunosuppressive medications used, and
the number of pneumococcal vaccination
indications other than medications and age.
Statistical Analyses
We analyzed differences between the QI
and comparison groups in demographics,
care delivery, health, or immunization status
at initial observation. We calculated the
unadjusted percentage of patients at each
immunization level within each group at
initial and final observation. We then used
unadjusted and adjusted ordered logit
difference-in-difference models to test for
significant changes in immunization levels
for the two groups. The unadjusted model
included group, time, and group by time
interaction. The adjusted model added
gender, age, insurance, a count of prior year
office-based visits, visit type, and the
number of indications for vaccination.
Models accounted for non-independence of
initial and final observations. The adjusted
model was used to generate the average
adjusted probabilities of persons in the QI
and comparison group being at each level of
immunization at initial and final observations
(eMethods).
Additional analyses included an examination
of associations between immunization levels
at initial observation and the presence and
duration of immunosuppressive medication
use prior to initial observation. We also
analyzed data for the subset of patients who
were newly prescribed immunosuppressive
medication during the project to evaluate the
effectiveness of the intervention on this
group. Last, we conducted analyses that
included only persons in the QI group who
were not fully immunized at initial
observation to identify factors associated
with non-receipt of a vaccination in this
group (eMethods).
All statistical testing was two-sided and used
Stata 14.2 [StataCorp; College Station, TX].
Significance was tested at p<0.05.
Our analysis included 201 patients with
planned or existing immunosuppression
attending an initial or follow-up dermatology
visit. Of these, 146 (72.6%; 91 from Clinic #1
and 55 from Clinic #2) were in the QI group
and 55 (27.4%; 41 from Clinic #1 and 14
from Clinic #2) in the comparison group.
While the comparison group contained a
RESULTS
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Table 1. Characteristics of immunosuppressed patients included in analyses, total and by quality improvement (QI) versus comparison group.
Variable Categories Total
n=201
Column % (95% CI)
QI Group
n=146
Column % (95% CI)
Comparison Group
n=55
Column % (95% CI)
p-valuea
Pneumococcal immunization status
at initial observation
No immunization 67.2 (60.3, 73.4) 69.9 (61.9, 76.8) 60.0 (46.4, 72.2) 0.329
Partially immunized 22.4 (17.1, 28.7) 18.5 (13.0, 25.7) 32.7 (21.5, 46.3)
Fully immunized 10.5 (6.9, 15.5) 11.6 (7.3, 18.0) 7.3 (2.7, 18.1)
Gender
Female 65.6 (58.8, 72.0) 66.4 (58.3, 73.7) 63.6 (50.0, 75.4) 0.709
Male 34.3 (28.0, 41.2) 33.6 (26.3, 41.7) 36.4 (24.6, 50.0)
Age
<=34 17.9 (13.2, 23.9) 19.9 (14.1, 27.2) 12.7 (6.1, 24.6) 0.307
35-44 17.9 (13.2, 23.9) 19.9 (14.1, 27.2) 12.7 (6.1, 24.6)
45-54 20.9 (15.8, 27.1) 17.8 (12.4, 24.9) 29.1 (18.5, 42.6)
55-64 25.4 (19.8, 31.9) 24.7 (18.3, 32.4) 27.3 (17.0, 40.7)
>=65 17.9 (13.2, 23.9) 17.8 (12.4, 24.9) 18.2 (10.0, 30.8)
Race/Ethnicity
White non-Hispanic 37.8 (31.3, 44.8) 40.4 (32.7, 48.6) 30.9 (20.0, 44.4) 0.162
Black non-Hispanic 23.9 (18.4, 30.3) 19.9 (14.1, 27.2) 34.5 (23.1, 48.1)
Hispanic 31.8 (25.7, 38.7) 33.6 (26.3, 41.7) 27.3 (17.0, 40.7)
Other race/ethnicity 6.5 (3.8, 10.9) 6.2 (3.2, 11.5) 7.3 (2.7, 18.1)
Primary insurance
Private 11 (7.3, 16.1) 11.6 (7.3, 18.0) 9.1 (3.8, 20.3) 0.176
Public (Medicare or Medicaid) 52.2 (45.3, 59.1) 56.2 (47.9, 64.1) 41.8 (29.4, 55.3)
County program 26.9 (21.1, 33.5) 23.3 (17.1, 30.9) 36.4 (24.6, 50.0)
Uninsured 10 (6.5, 15.0) 8.9 (5.2, 14.8) 12.7 (6.1, 24.6)
Patient used translatorb Yes 19.9 (13.2, 23.9) 17.8 (12.4, 24.9) 18.2 (10.0, 30.8) 0.951
Count of past year office-based
contacts (all provider specialties)
0-3 visits 23.4 (18.0, 29.8) 28.1 (21.3, 36.0) 10.9 (4.9, 22.5) 0.068
4-8 visits 31.3 (25.3, 38.1) 29.5 (22.6, 37.4) 36.4 (24.6, 50.0)
9-14 visits 27.4 (21.6, 34.0) 26.7 (20.1, 34.5) 29.1 (18.5, 42.6)
>=15 visits 17.9 (13.2, 23.9) 15.8 (10.7, 22.7) 23.6 (14.1, 36.8)
Visit type at initial observation
Initial 23.4 (18.0, 29.8) 19.2 (13.5, 26.5) 34.5 (23.1, 48.1) 0.022
Follow-up 76.6 (70.2, 82.0) 80.8 (73.5, 86.5) 65.5 (51.9, 76.9)
Number of comorbid conditionsb
None 14.4 (10.2, 20.0) 15.1 (10.1, 21.9) 12.7 (6.2, 24.5) 0.681
1-3 conditions 47.8 (40.9, 54.7) 48.6 (40.6, 56.8) 45.5 (32.8, 58.7)
4 or more conditions 37.8 (31.3, 44.8) 36.3 (28.9, 44.4) 41.8 (29.5, 55.2)
Immunosuppressive medications
used prior to initial observationc
Yes 83.1 (77.2, 87.7) 83.6 (76.6, 88.8) 81.8 (69.2, 90.0) 0.769
Condition for which individual was
prescribed immunosuppressive
medication(s) (all provider
specialties)
Psoriasis with or without psoriatic arthritis 70.2 (63.4, 76.1) 69.2 (61.1, 76.2) 72.7 (59.3, 83.0) 0.474
Hidradenitis suppurativa 9.5 (6.1, 14.4) 9.6 (5.7, 15.6) 9.1 (3.8, 20.3)
Connective tissue disease 8.5 (5.3, 13.2) 9.6 (5.7, 15.6) 5.5 (1.7, 15.8)
Rheumatoid arthritis 5.5 (3.0, 9.7) 4.8 (2.3, 9.8) 7.3 (2.7, 18.1)
Vesiculobullous disease 4 (2.0, 7.8) 4.8 (2.3, 9.8) 1.8 (0.2, 12.1)
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Atopic dermatitis 1 (0.2, 3.9) 0.7 (0.1, 4.8) 1.8 (0.2, 12.1)
Inflammatory bowel disease 0.5 (0.1, 3.5) 0.7 (0.1, 4.8) 0
Chronic lichenoid inflammatory disease 0.5 (0.1, 3.5) 0.7 (0.1, 4.8) 0
Organ transplant 0.5 (0.1, 3.5) 0 1.8 (0.2, 12.1)
Current number of
immunosuppressive medications
prescribed (all provider specialties)
1 medication 80.6 (74.5, 85.5) 80.1 (72.8, 85.9) 81.8 (69.2, 90.0) 0.788
2 medications 17.4 (12.7, 23.3) 17.8 (12.4, 24.9) 16.4 (8.7, 28.8)
3 medications 2 (0.7, 5.2) 2.1 (0.7, 6.2) 1.8 (0.2, 12.1)
Prescribed biologicsd Yes 80.1 (73.9, 85.1) 82.2 (75.1, 87.6) 74.5 (61.3, 84.4) 0.226
Prescribed antimetabolites,
corticosteroids, or other
immunosuppressived
Yes 31.3 (25.3, 38.1) 30.8 (23.8, 38.8) 32.7 (21.6, 46.1) 0.795
Number of indications for
immunization other than
medication(s) and aged
0 indications 45.3 (38.5, 52.2) 44.5 (36.6, 52.7) 47.3 (34.4, 60.5) 0.765
1 indication 32.8 (26.6, 39.7) 33.6 (26.3, 41.7) 30.9 (20.0, 44.4)
2 indications 14.9 (10.6, 20.6) 14.4 (9.5, 21.1) 16.4 (8.7, 28.8)
3 indications 6 (3.4, 10.3) 6.9 (3.7, 12.3) 3.6 (0.9, 13.7)
4 indications 1 (0.2, 3.9) 0.7 (0.1, 4.8) 1.8 (0.2, 12.1)
a Significance was evaluated using Pearson’s chi-squared tests and Wilcoxon rank-sum tests for categorical and ordinal variables, respectively.
b Comorbid conditions included asthma, CAD, cancer, chronic pain, COPD, chronic renal failure, diabetes, high cholesterol, hypertension, hypothyroidism, psychiatric, seizures GERD, OAA, or other conditions.
c Dichotomous yes/no variables only display data for the "Yes" category.
d Indications include heart disease (CHF or CAD), diabetes, lung disease (COPD or asthma), chronic renal failure, or being a current smoker. Possible range 0-5, actual range 0-4
Table 2. Unadjusted and adjusted column percentages reflecting immunization status by group and point in time. N=201.
QI Group (N=146) Comparison Group (n=55) p-
value
QI Group (N=146) Comparison Group (n=55) p-
value
Unadjusted Column Percentages (95% CI) Adjusted Column Percentagesa (95% CI)
Immunization
Status
Initial
observation
Final
observation
Initial
observation
Final
observation
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 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
18.5
(13.0, 25.7)
47.9
(39.9, 56.1)
32.7
(21.5, 46.3)
32.7
(21.5, 46.3)
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
11.6
(7.3, 18.0)
38.4
(30.8, 46.6)
7.3
(2.7, 18.1)
7.3
(2.7, 18.1)
7.7
(3.9, 11.4)
40.6
(0.34, 0.47)
9.2
(5.0, 13.4)
9.2
(5.0, 13.4)
a Adjusted column percentages are the average predicted probabilities calculated based on results of a multivariable ordered logit model (see Table 4 in the Supplement); probabilities multiplied by 100
and expressed as percentages
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higher proportion of new patients (p-value =
0.022), we found no significant differences
between QI and comparison groups for
other demographic, care delivery, or health
variables (p>0.05 for each; Table 1).
While our unadjusted analyses identified no
significant group differences in immunization
status at initial observation (p=0.329; Table
1), immunization status differed significantly
by QI/comparison group at the final
observation (p<0.001; Table 2). Of the 102
patients in the QI group with no
pneumococcal immunizations at initial
observation, 80.4% (95% CI: 71.4%, 87.1%)
received at least one pneumonia vaccination
by the final observation. For the 27 patients
in the QI group with partial immunization at
project initiation, 85.2% (95% CI: 65.9%,
94.5%) received at least one pneumonia
vaccination. Overall, 81.4% (95% CI: 73.6,
87.3) of patients in the QI group without full
immunization at initial observation received
at least one vaccination by the final
observation. Pneumococcal immunization
statuses did not change during the project
period within the comparison group (Table
2).
Regression analyses identified that the QI
group had a significant change in
immunization status compared to the
comparison group (Table 2; unadjusted
difference-in-difference p<0.001, Table 3).
Immunization acceptance patterns for the
subset of 34 patients not previously on
immunosuppression who were prescribed
immunosuppressive medication during the
project were similar. Of those with new
prescriptions, 75% (18/24; 95% CI: 53.0,
88.9) of the QI group and 0% (0/10) of the
comparison group received at least one
pneumococcal immunization by final
observation (p<0.001; data not shown).
Table 3: Results of unadjusted ordered logit model
examining differences in immunization status for the
QI group versus comparison group at initial versus
final observation. Analysis accounts for repeated
measures (n=201).
Odds
Ratio
(OR)
95% Confidence
Interval of OR
p-value
Group
Comparison
group
1.00 (ref)
QI group 0.72 0.38 1.37 0.321
Time
Initial
observation
1.00 (ref)
Final
observation
1.00 . . .
Interaction
Group*Time 10.14 6.71 15.34 <0.001
Findings were similar after adjusting for
demographic, clinical, and other factors, with
a significant change in immunization status
at final observation among patients in the QI
group and no change in the comparison
group (Table 2). Consequently, there was a
significant interaction between group and
time (p=<0.001; Table 4). Figure 1 visualizes
the predicted probabilities of persons in the
QI group being immunized at initial versus
final observation. For the QI group, the
predicted probabilities of having no, partial,
or full immunizations at initial observation
were 0.66, 0.26, and 0.08, respectively. At
the time of final observation for the QI group,
the predicted probabilities of having no,
partial, or full immunizations were 0.16,
0.43, and 0.41, respectively. Predicted
probabilities for the comparison group of
having no, partial, or full immunizations at
initial observation were 0.62, 0.29, and 0.09,
respectively and did not change during the
project (Table 2).
Controlling for time, group, and other
factors, patients 65 years of age or older
had significantly greater odds of having a
higher immunization status compared to
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Figure 1. Adjusted average predicted probabilities of persons in the QI group being unimmunized, partially
immunized, and fully immunized at initial and final observations. Probabilities were generated based on the results
of the multivariable ordered logit model detailed in eTable 2 of the Supplement.
younger persons (p=<0.001). A significant
association was also found between the
number of risk factors for pneumonia and
higher immunization statuses (p=0.034).
Conversely, the number of prior office visits
was not significantly associated with
immunization level after controlling for other
factors (Table 4; p>0.05 for all levels).
Our analyses investigating variations in the
intervention's effectiveness indicated
uninsured patients were less likely to receive
a vaccination relative to insured patients
(unadjusted p=0.007, adjusted p=0.015;
Table 5). Further, regardless of group,
immunosuppressive medication use before
initial observation was not significantly
associated with immunization status. This
was true whether medication use was
dichotomized (z=-0.35, p=0.725) or
categorized based on immunosuppression
duration (r2=0.11, p=0.119; Table 6).
Pneumococcal immunizations are indicated
for adults at risk of severe disease,
hospitalization, and death from
pneumococcal illnesses28. This public health
recommendation is incompletely
implemented worldwide leaving a large gap
DISCUSSION
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Table 4. Results of multivariable ordered logit model.
The model's dependent variable is immunization
status; the main predictor variables are group, time
and the group by time interaction. Analysis accounts
for repeated measures (n=201).
Odds
Ratio
(OR)
95%
Confidence
Interval of OR
p-value
Group
Comparison
group
1.00 (ref)
QI group 0.77 0.38 1.59 0.485
Time
Initial observation 1.00 (ref)
Final observation 1.00 . . .
Interaction
Group*Time 19.12 11.53 31.72 <0.001
Gender
Female 1.00 (ref)
Male 1.24 0.68 2.27 0.479
Age
<=34 1.00 (ref)
35-44 0.65 0.26 1.61 0.353
45-54 0.87 0.39 1.95 0.739
55-64 1.18 0.50 2.82 0.703
>=65 17.64 5.51 56.48 <0.001
Insurance
Private 1.00 (ref)
Public (Medicare
or Medicaid)
1.34 0.44 4.08 0.604
County program 1.58 0.55 4.53 0.393
Uninsured 0.34 0.08 1.43 0.141
Count of prior
office-based
contacts (all
provider
specialties)
0-3 visits 1.00 (ref)
4-8 visits 0.86 0.39 1.91 0.718
9-14 visits 1.16 0.51 2.67 0.720
>=15 visits 1.78 0.71 4.45 0.216
Visit type at
project initiation
Initial 1.00 (ref)
Follow-up 1.01 0.49 2.10 0.979
Number of risk
factors other
than
medication(s)
and agea
Count variable 1.46 1.03 2.08 0.034
a 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.
in vaccine coverage and many individuals at
risk for preventable health loss 12-15. We
implemented a QI project incorporating
patient education with the opportunity for
immediate immunization for patients
prescribed new or existing
immunosuppressive therapies in a specialty
care clinic. We found 81% (105 of 129) of
patients with incomplete pneumococcal
immunization accepted immediate
vaccination. These data demonstrate that
immunization coverage in patients on
immunosuppressive medications can be
markedly improved by direct physician
recommendation with convenient, immediate
availability of the pneumococcal vaccine
during specialty care.
The ACIP guidelines for pneumococcal
immunization are complex. There are two
nonequivalent pneumococcal vaccines,
PCV-13 and PPSV23 with indications by
age, specific illnesses, lifestyle behaviors,
sequence of administration, and broad
categories of risk including
immunocompromise 35. Recommendations
are for single and in other scenarios for both
vaccines. In circumstances where both
vaccines are recommended, a specific
sequence is recommended, with PCV-13
initially then PPSV23 given 8 weeks later.
Patients in the QI program were likely
immunized for other indications. We found
patients were more likely to be vaccinated if
they were over 65 or had other indications
for pneumococcal immunization (Table 4).
The EMR system of both institutions has an
automatic care-gap function to remind
clinicians of recommended practices
compared to current care. Currently, both
sites include age 65 or older as the only
trigger for care-gap pneumococcal
immunization reminder. The EMR was
therefore an immunization barrier at both
institutions. Improved EMR programming
could improve reminders for pneumococcal
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May 2021 Volume 5 Issue 3
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immunizations, improve care-gap
recognition, and potentially improve
immunization uptake.
Table 5. Results of logistic regression model
examining adjusted associations between receipt of
one or more pneumonia vaccinations during the QI
project and patient characteristics. Includes persons
in the QI group who were not already fully immunized
at initial observation (n=129).
Odds
Ratio
(OR)
95%
Confidence
Interval of
OR
p-
value
Gender
Female 1.00 (ref)
Male 1.06 0.35 3.24 0.917
Age
<=34 1.00 (ref)
35-44 0.81 0.20 3.37 0.777
45-54 3.79 0.56 25.67 0.172
55-64 1.40 0.26 7.64 0.699
>=65 1.06 0.15 7.50 0.955
Insurance
Private 1.00 (ref)
Public (Medicare or
Medicaid)
0.89 0.15 5.22 0.893
County program 1.10 0.15 8.06 0.927
Uninsured 0.07 0.01 0.59 0.015
Patient Used Translator
Yes 1.00 (ref)
No 7.14 0.91 56.31 0.062
Count of prior office-
based contacts (all
provider specialties)
0-3 visits 1.00 (ref)
4-8 visits 0.62 0.17 2.28 0.473
9-14 visits 0.85 0.20 3.68 0.829
>=15 visits 0.74 0.14 3.82 0.717
Visit type at project
initiation
Initial 1.00 (ref)
Follow-up 1.98 0.52 7.51 0.317
Number of indications
other than medication(s)
and agea
Count variable 0.98 0.50 1.91 0.952
Immunosuppressive
medications used prior to
initial observation
No 1.00 (ref)
Yes 0.40 0.08 2.06 0.271
a 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
Other systematic barriers to optimal
immunization include ambiguity around who
is responsible for vaccination. Patients with
multiple specialty healthcare system
contacts may have fewer primary care
immunization opportunities36. The official
position of the ACIP is that every healthcare
provider has a fundamental responsibility for
ensuring patients are current with
immunizations. The National Psoriasis
Foundation recommends that dermatologists
give immunization education but vaccination
should be by primary care clinicians 23.
Another systems barrier is incomplete
communication between multiple providers.
Patients, especially those with chronic
health problems, may require care from
multiple specialists as well as primary care
providers, and a patient's immunization
history can be uncertain, inaccurate, or
imperfectly shared between these locations
36,37.
We evaluated such barriers in our local
context. Since every clinician could act as a
potential immunizer, we sought to identify
whether the frequency and type of outpatient
visits over time impacted immunization
status at first observation. We identified
office-based visits with primary,
dermatological, and other specialty
providers for all patients during the 12
months prior to first observation. We found
that the number of prior office visits was not
significantly associated with immunization
level after controlling for other factors (Table
4). This demonstrates "diffusion of
responsibility" or a situation where if
everyone is responsible for immunizations,
no one is responsible. One solution would
be for the ACIP to define which provider is
responsible for certain immunizations more
precisely. The indication for immunization
could direct consensus to standardize
accountability. In this regard, the provider
created indications could be managed by
the prescribing provider. At the same time,
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Table 6. Association between immunization status at initial observation and prior immunosuppressive use.
Immunization
Status at Initial
Observation
Total
n=201
%
(95% CI)
Used immunosuppressive
medications prior to initial
observation
% (95% CI)
Time on immunosuppressive medications prior to initial observation
% (95% CI)
No
n=34
Yes
n=167
p-
value
None: New
User
n=34
<1 Year
n=36
1 to <3
years
n=48
3 to <6
years
n=33
≥6 years
n=50
p-
value
No immunization 67.2
(60.3, 73.4)
70.6
(53.0,
83.6)
66.5
(58.9,
73.3)
0.725 70.6
(53.0,
83.6)
77.8
(61.1,
88.6)
70.8
(56.3,
82.1)
57.6
(40.1,
73.3)
60.0
(45.8,
72.7)
0.119
Partially
immunized
22.4
(17.1, 28.7)
17.6
(8.0,
34.5)
23.3
(17.5,
30.4)
17.6
(8.0, 34.5)
8.3
(2.6,
23.3)
25.0
(14.6,
39.3)
30.3
(16.9,
48.1)
28.0
(17.2,
42.1)
Fully immunized 10.5
(6.9, 15.5)
11.8
(4.4,
27.9)
10.2
(6.4,
15.8)
11.8
(4.4, 27.9)
13.9
(5.8,
29.7)
4.2
(1.0,
15.5)
12.1
(4.5, 28.6)
12.0
(5.4, 24.5)
routine immunizations may be best done by
primary care clinicians.
The cost of care affects adherence to health
care immunization recommendations38,39. A
2012 National Health Interview Survey
showed pneumococcal coverage of adults at
high-risk for pneumococcal pneumonia was
9.8% versus 23.0% in underinsured patients
vs. insured patients 40. In our QI project, we
also identified cost as a barrier to
immunization. Uninsured patients were the
only group in which the QI intervention was
not successful (unadjusted p=0.007,
adjusted p=0.015; Table 5). In pediatric
populations, the Vaccine For Children
program covers vaccine costs for children
unable to pay41. A similar public program for
adults could reduce vaccine disparities and
increase uninsured patients' opportunities to
be immunized.
Immunosuppression attenuates the
immunological response to vaccination, and
ideally, patients complete their
immunizations before starting
immunosuppressive therapies42. In this QI
project where immunizations were
immediately available as part of the process
of initiating immunosuppressive treatment,
75% of those in the QI group (18/24; 95%
CI: 53.0, 88.9) and 0% in the comparison
group (0/10) received at least one
pneumococcal vaccination before starting
immunosuppression. Our results suggest
that one potential method to improve
immunization coverage of patients preparing
to initiate immunosuppressive medications
would be to have immunizations
immediately available for administration as
part of the immunosuppressant preparation
process.
There have been mixed results from quality
improvement and other initiatives to
increase immunization coverage43-47.
Ineffective strategies included patient
education by nursing, point-of-care paper
worksheets with questionnaires, and letters
to patients 31. Successful strategies have
included designating non-physician staff
responsible for vaccine administration,
designated clinics for preventive care,
standing orders, and email reminders or
prompts to providers29,30,48-50. The most
effective strategies have been system-level
interventions. These included electronic
reminders with linked order sets, physician
auditing and feedback, patient outreach, and
printed prescriptions. Prior research
examining the impact of these strategies
found that the receipt rate for any
pneumococcal immunization increased
160%, from roughly 29% to 46%49. Our QI
approach of physician recommendation with
convenient, immediate availability of the
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pneumococcal vaccine during specialty care
had 1.5 times this impact -- the predicted
probability for an immune suppressed
patient to have received one or more
immunizations against pneumococcal
pneumonia rose 247% in the presence of
our intervention, from 34% to 84%. Given
our experience it is likely this method could
improve care if it were adopted by others.
There are several limitations to our
analyses. First, our data are geographically
and demographically narrow, representing
the experience of two dermatology practices
in north-central Texas primarily serving
patient populations eligible for subsidized
medical care. Our patient population may
therefore not represent the overall patient
population on immunosuppressive
medications. Second, the study was
retrospective in design, and data may have
been missed or not collected. This may
impact some areas of the study's power.
Third, although patients from two clinics
were included in analyses, small sample
sizes precluded us from statistically
adjusting for the multi-site nature of the
data51. Larger sample sizes of patients
seen in a greater number of specialty
practices by a larger number of clinicians
are needed to replicate our findings and
solidify intervention effect estimates. We
analyzed the combined effect of physician
recommendation, patient education, and the
immediate availability of immunizations. As
a result, we cannot determine the extent to
which each intervention resulted in
increased vaccine uptake.
We observed, then successfully addressed,
a substantial gap between recommended
pneumococcal immunization in
immunosuppressed patients and actual
immunization coverage among adult
patients receiving specialist dermatology
care. A dual strategy of direct patient
education by the treating physician with
immediate availability of vaccine and
administration resulted in 81% of these high-
risk patients obtaining full or partial
pneumococcal immunization, a 247%
increase in the predicted probability of full or
partial immunity over baseline. Wider
adoption of this model and its adaptation to
other immunizations and settings is an
important opportunity to reduce vaccine-
preventable illness, including COVID-19,
and improve population health.
Acknowledgements: We would like to acknowledge
JPS Health Network and University of North Texas
Health Science Center for the continued emphasis on
safe, high quality patient care, and support of this
quality improvement initiative.
Conflict of Interest Disclosures: None
Funding: None
Corresponding Author:
Dr. Stephen Weis
Stephen Weis, DO
The university of North Texas Health Science Center
at Fort Worth
Department of Dermatology
855 Montgomery St
Fort Worth, TX 76107
Phone 817-735-0278
Email stephen.weis@unthsc.edu
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