Quality Improvement Methodology Increases Pneumococcal Vaccination for Patients With Rheumatic Diseases


Pediatric patients with rheumatic disease, such as systemic lupus erythematosus, mixed connective tissue disease, juvenile dermatomyositis, and systemic vasculitis are at an increased risk of serious infection.

Investigators reported that quality improvement methodology increased and sustained pneumococcal vaccination rates for individuals who are high-risk and immunosuppressive with rheumatic diseases, according to results of a study published in Pediatric Quality and Safety.

PNEUMOCOCCAL VACCINE text is written on a vial whose ampoule is held by a hand in a medical disposable glove. | Image Credit: Iryna - stock.adobe.com

Image Credit: Iryna - stock.adobe.com

According to the study authors, pediatric patients with rheumatic disease are at an increased risk of serious infection because of underlying disease-related immune dysfunction and immunosuppressive medication. Patients who are immunosuppressed cannot receive live virus vaccines, but attenuated vaccines are recommended, including the 13-valent pneumococcal conjugate vaccine (PCV13) and 23-valent pneumococcal polysaccharide vaccine (PPSV23). However, PPSV23 is separate from routine vaccination for healthy children and PCV13 was not available until 2010, therefore, investigators aimed to increase the vaccination rate for individuals with systemic lupus erythematosus (SLE) and mixed connective tissue disease (MCTD), according to the study authors.

The investigators’ goal was to increase the pneumococcal vaccination rates for those with SLE and MCTD from 9.6% to 80%, respectively, within 1 year, with a second aim of increasing the percentage of patients with immunosuppressive SLE, MCTD, juvenile dermatomyositis (JDM), and systemic vasculitis who received the vaccinations from 62.6% to 80%, respectively, within 1 year.

Initially, the study project team included 3 physicians, a clinic nurse, and a nurse manager, with the primary drivers of the team being pre-visit planning, immunization record availability, and engagement of patients, physicians, nurses, and staff; the team also identified potential barriers to vaccination. Additionally, the investigators used quality improvement methodology to create a process map for steps to administer the vaccine in the clinic and generated a possible, implement, challenge, kick out (PICK) chart for intervention-based change and impact.

Additionally, the study authors said the rheumatology division and the multidivisional multidisciplinary team at the hospital worked together for shared improvements to overcome barriers to vaccination for the high-risk population. There were education opportunities for pneumococcal vaccine and current vaccine schedule recommendations for immunosuppressed patients as well as a review over the pneumococcal vaccine algorithm, which was posted in the common workroom.

For pre-visits, the team identified high-risk patients who were eligible for a pneumococcal vaccine, which was emailed to the physicians by the administrative assistant. The physician determined if vaccination was appropriate based on the current visit, medications, and prior vaccination status. Additionally, there were reminders and updates about pneumococcal vaccination to the rheumatology e-newsletter. The team would also report performance updates at regular time periods, according to the study authors.

In phase 1, investigators reported 276 patient encounters who had SLE or MCTD. In phase 2, there were 549 patient encounters with 334 who had SLE or MCTD and 215 who had JDM or vasculitis, according to the study authors. The age range of the patients in the study was 1 year old to 21 years old.

The results showed that the median vaccination rates for PCV13 for SLE and MCTD patients in phase 1 was 22.5%. After 2 shifts in data, according to the results, the final vaccination rate was 92.3%. For PPSV23, the baseline vaccination rate was 0% and increased to 92.6%. The combined vaccination rates increased from 9.6% to 91.1% with 3 shifts in data, and the rate was sustained for 2 years and through phase 2, according to the study authors.

For phase 2, the PCV13 rates for all 4 disease states increased from 68.8% to 93.4%. For PPSV23, there was a special cause noted that increased vaccination from 65.2% to 88.5%. The combined vaccination rate rose from 62.6% to 86.5% and was sustained for over 1 year.

Investigators did not report any significant known adverse events to vaccination.

Harris JG, Jones JT, Favier L, et al. Improving Pneumococcal Vaccination Rates in Immunosuppressed Pediatric Patients with Rheumatic Disease. Pediatr Qual Saf. 2024;9(3):e725. Published 2024 May 9. doi:10.1097/pq9.0000000000000725
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