title: A Multifaceted Intervention to Improve Influenza, Pneumococcal, and Herpes Zoster Vaccination among Patients with Rheumatoid Arthritis.
abstract: Vaccination rates for influenza, pneumococcus, and zoster in patients with rheumatoid arthritis (RA) have remained low. Simple electronic or paper reminders have produced only small increases in vaccination rates. We sought to identify a more effective approach to improve vaccination rates.
  
  
  
  We conducted a system-level intervention at an academic rheumatology clinic that included electronic reminders with linked order sets, physician auditing and feedback, patient outreach, and optional printed prescriptions for zoster vaccination at an outside pharmacy.
  
  
  
  We targeted 1255 eligible patients with RA. There was no change in patients' self-reported influenza vaccination rates, although the baseline self-reported rate was already high and much higher than that documented in the electronic health record. Pneumococcal vaccination rates increased from 28.7% to 45.8%; in regression analysis, the rate of change in pneumococcal vaccination increased by 9.4% per year above baseline trends (95% CI 3.9-15.5, p = 0.002). The rate of zoster vaccination increased from 2.5% to 4.5% overall (p = 0.01) and from 3.0% to 6.6% among patients not receiving biologic therapy that precluded zoster vaccination.
  
  
  
  Although the intervention improved pneumococcal and zoster vaccination rates, the improvement in pneumococcal vaccination rate was less than expected, and the zoster vaccination rate remained low even for ideal candidates. Likely barriers include lack of familiarity and difficulty using electronic reminders and order sets, uncertainty about the value and safety of recommended vaccines, and uncertainty about patients' insurance coverage and prior vaccination history. Future interventions should include strategies to address these.
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, and Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.D.W. Baker, MD, MPH, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; T. Brown, MPH, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; J.Y. Lee, MS, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; A. Ozanich, PA, Division of Rheumatology, Northwestern University Feinberg School of Medicine; D.T. Liss, PhD, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; D.S. Sandler, MD, Division of Rheumatology, Northwestern University Feinberg School of Medicine; E.M. Ruderman, MD, Professor of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine.
authors.forename: David W
authors.initials: DW
authors.lastname: Baker
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, and Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.D.W. Baker, MD, MPH, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; T. Brown, MPH, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; J.Y. Lee, MS, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; A. Ozanich, PA, Division of Rheumatology, Northwestern University Feinberg School of Medicine; D.T. Liss, PhD, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; D.S. Sandler, MD, Division of Rheumatology, Northwestern University Feinberg School of Medicine; E.M. Ruderman, MD, Professor of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine.
authors.forename: Tiffany
authors.initials: T
authors.lastname: Brown
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, and Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.D.W. Baker, MD, MPH, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; T. Brown, MPH, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; J.Y. Lee, MS, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; A. Ozanich, PA, Division of Rheumatology, Northwestern University Feinberg School of Medicine; D.T. Liss, PhD, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; D.S. Sandler, MD, Division of Rheumatology, Northwestern University Feinberg School of Medicine; E.M. Ruderman, MD, Professor of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine.
authors.forename: Ji Young
authors.initials: JY
authors.lastname: Lee
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, and Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.D.W. Baker, MD, MPH, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; T. Brown, MPH, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; J.Y. Lee, MS, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; A. Ozanich, PA, Division of Rheumatology, Northwestern University Feinberg School of Medicine; D.T. Liss, PhD, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; D.S. Sandler, MD, Division of Rheumatology, Northwestern University Feinberg School of Medicine; E.M. Ruderman, MD, Professor of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine.
authors.forename: Amanda
authors.initials: A
authors.lastname: Ozanich
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, and Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.D.W. Baker, MD, MPH, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; T. Brown, MPH, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; J.Y. Lee, MS, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; A. Ozanich, PA, Division of Rheumatology, Northwestern University Feinberg School of Medicine; D.T. Liss, PhD, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; D.S. Sandler, MD, Division of Rheumatology, Northwestern University Feinberg School of Medicine; E.M. Ruderman, MD, Professor of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine.
authors.forename: David T
authors.initials: DT
authors.lastname: Liss
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, and Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.D.W. Baker, MD, MPH, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; T. Brown, MPH, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; J.Y. Lee, MS, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; A. Ozanich, PA, Division of Rheumatology, Northwestern University Feinberg School of Medicine; D.T. Liss, PhD, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; D.S. Sandler, MD, Division of Rheumatology, Northwestern University Feinberg School of Medicine; E.M. Ruderman, MD, Professor of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine.
authors.forename: Diana S
authors.initials: DS
authors.lastname: Sandler
authors.affiliation: From the Division of General Internal Medicine and Geriatrics, and Division of Rheumatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.D.W. Baker, MD, MPH, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; T. Brown, MPH, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; J.Y. Lee, MS, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; A. Ozanich, PA, Division of Rheumatology, Northwestern University Feinberg School of Medicine; D.T. Liss, PhD, Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine; D.S. Sandler, MD, Division of Rheumatology, Northwestern University Feinberg School of Medicine; E.M. Ruderman, MD, Professor of Medicine, Division of Rheumatology, Northwestern University Feinberg School of Medicine. e-ruderman@northwestern.edu.
authors.forename: Eric M
authors.initials: EM
authors.lastname: Ruderman
mesh_terms: D000328:Adult; D000368:Aged; D001172:Arthritis, Rheumatoid; D057286:Electronic Health Records; D005260:Female; D006562:Herpes Zoster / Q000517:prevention & control*; D053061:Herpes Zoster Vaccine; D006801:Humans; D017589:Immunization Programs; D007252:Influenza Vaccines; D007251:Influenza, Human / Q000517:prevention & control*; D008297:Male; D008875:Middle Aged; D011008:Pneumococcal Infections / Q000517:prevention & control*; D022242:Pneumococcal Vaccines; D014611:Vaccination / Q000706:statistics & numerical data*
chemical_list: D053061:Herpes Zoster Vaccine; D007252:Influenza Vaccines; D022242:Pneumococcal Vaccines
keywords: ELECTRONIC HEALTH RECORDS; HERPES ZOSTER; QUALITY IMPROVEMENT; VACCINATION