Sheth Heena, Moreland Larry, Peterson Hilary, Aggarwal Rohit
From the Department of Medicine, University of Pittsburgh School of Medicine, and Rheumatology Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
H. Sheth, MD, MPH, Department of Medicine, University of Pittsburgh School of Medicine; L. Moreland, MD, Rheumatology Division, Department of Medicine, University of Pittsburgh Medical Center; H. Peterson, BA, Rheumatology Division, Department of Medicine, University of Pittsburgh Medical Center; R. Aggarwal, MD, MS, Rheumatology Division, Department of Medicine, University of Pittsburgh Medical Center.
J Rheumatol. 2017 Jan;44(1):11-17. doi: 10.3899/jrheum.160179. Epub 2016 Nov 15.
To improve herpes zoster (HZ) vaccination rates in high-risk patients with rheumatoid arthritis (RA) being treated with immunosuppressive therapy.
This quality improvement project was based on the pre- and post-intervention design. The project targeted all patients with RA over the age of 60 years while being treated with immunosuppressive therapy (not with biologics) seen in 13 rheumatology outpatient clinics. The study period was from July 2012 to June 2013 for the pre-intervention and February 2014 to January 2015 for the post-intervention phase. The electronic best practice alert (BPA) for HZ vaccination was developed; it appeared on electronic medical records during registration and medication reconciliation of the eligible patient by the medical assistant. The BPA was designed to electronically identify patient eligibility and to enable the physician to order the vaccine or to document refusal or deferral reason. Education regarding vaccine guidelines, BPA, vaccination process, and feedback were crucial components of the project interventions. The vaccination rates were compared using the chi-square test.
We evaluated 1823 and 1554 eligible patients with RA during the pre-intervention and post-intervention phases, respectively. The HZ vaccination rates, reported as patients vaccinated among all eligible patients, improved significantly from the pre-intervention period of 10.1% (184/1823) to 51.7% (804/1554) during the intervention phase (p < 0.0001). The documentation rates (vaccine received, vaccine ordered, patient refusal, and deferral reasons) increased from 28% (510/1823) to 72.9% (1133/1554; p < 0.0001). The HZ infection rates decreased significantly from 2% to 0.3% (p = 0.002).
Electronic identification of vaccine eligibility and BPA significantly improved HZ vaccination rates. The process required minimal modification of clinic work flow and did not burden the physician's time, and has the potential for self-sustainability and generalizability.
提高接受免疫抑制治疗的类风湿关节炎（RA）高危患者的带状疱疹（HZ）疫苗接种率。
本质量改进项目基于干预前和干预后设计。该项目针对13个风湿病门诊中所有60岁以上接受免疫抑制治疗（非生物制剂）的RA患者。研究期为干预前期2012年7月至2013年6月，干预后期2014年2月至2015年1月。开发了HZ疫苗接种的电子最佳实践警报（BPA）；它在医疗助理对符合条件的患者进行登记和药物核对时出现在电子病历上。BPA旨在以电子方式确定患者是否符合条件，并使医生能够订购疫苗或记录拒绝或推迟接种的原因。关于疫苗指南、BPA、接种流程和反馈的教育是项目干预的关键组成部分。使用卡方检验比较疫苗接种率。
我们分别在干预前期和干预后期评估了1823例和1554例符合条件的RA患者。HZ疫苗接种率（报告为所有符合条件患者中接种疫苗的患者）从干预前期的10.1%（184/1823）显著提高到干预期的51.7%（804/1554）（p < 0.0001）。记录率（接种疫苗、订购疫苗、患者拒绝和推迟接种原因）从28%（510/1823）提高到72.9%（1133/1554；p < 0.0001）。HZ感染率从2%显著降至0.3%（p = 0.002）。
通过电子方式确定疫苗接种资格和BPA显著提高了HZ疫苗接种率。该流程只需对门诊工作流程进行最小程度的修改，且不占用医生时间，具有自我维持和推广的潜力。
