Aim to boost vaccinations in people with lupus to reduce use of acute care

BY HEIDI SPLETE


Preventive care and vaccination services for patients with systemic lupus erythematosus in an outpatient setting could have a significant impact on reducing hospitalizations for vaccine-preventable illnesses, based on data from more than 45,000 adults.

Approximately 25% of patients with systemic lupus erythematosus (SLE) are hospitalized each year, including for vaccine-preventable illnesses, wrote Candace H. Feldman, MD, of Brigham and Women's Hospital, Boston, and colleagues.

In a study published in Arthritis Care & Research, Dr. Feldman and colleagues reviewed Medicaid claims data from 29 states during 2000-2010 and identified 45,654 adults aged 18-65 years with prevalent SLE and 12 months' enrollment before the first SLE code.
By identifying populations of lupus patients at higher risk, strategies could be developed to improve vaccine uptake and access to outpatient care among the most vulnerable.
The researchers defined acute care use for vaccine-preventable illness as ED or hospital discharge visits for influenza, pneumococcal disease, meningococcal disease, herpes zoster, high‐grade cervical dysplasia/cervical cancer, and hepatitis B after the index date.

Overall,1,290 patients had at least one ED visit or hospitalization for a vaccine‐preventable illness (6.6 per 1,000 person‐years). Less than 10% of the SLE patients had billing claims for vaccinations in the prior 12 months, and 93% of the ED visits and hospitalizations for vaccine-preventable illnesses occurred in patients without prior claims for vaccinations.

The researchers also found a 22% higher risk of acute care visits among Black patients, compared with White patients. However, a greater number of outpatient visits was associated with a lower risk of acute care use for vaccine-preventable illnesses in a dose-dependent manner, with a hazard ratio of 0.74 for 6-10 outpatient visits and 0.67 for more than 10 outpatient visits, compared with none.

The study findings were limited by several factors including possible missing data on vaccinations, a focus solely on vaccine-preventable illnesses, and the inability to compare the incidence of infections between vaccinated and unvaccinated patients because of small sample sizes, the researchers noted.

However, the results were strengthened by the diverse population of Medicaid beneficiaries, the largest public health insurance in the United States serving low-income individuals. "By identifying populations of lupus patients at higher risk, strategies could be developed to improve vaccine uptake and access to outpatient care among the most vulnerable," they noted. "Health system–wide efforts are also needed to augment the quality of outpatient and preventive care to reduce the risk of avoidable outcomes, and the associated costs of acute care use among vulnerable populations."

Image credit: Marko Geber/DigitalVision/Getty Images
Over the study period [2000-2010], we observed a decrease in the incidence of acute care use for vaccine-preventable illnesses, and I suspect that rates have continued to decrease since then.

Recognizing the acute care burden

The study was important because of the known high rates of ED visits and hospitalizations among SLE patients, Dr. Feldman said in an interview. "We aimed to understand the burden of emergency department visits and hospitalizations among individuals with lupus that may be preventable if individuals received necessary vaccinations. We know that individuals with lupus, especially those on immunosuppressive medications, are susceptible to infections, and we hypothesized that a percentage of severe infections that result in acute care use may be avoidable if vaccinations were routinely provided."

Dr. Feldman said the researchers were somewhat surprised by the low percentage of SLE patients who had billing claims for vaccinations during the baseline period of the analysis. "While our main focus was on acute care use for vaccine-preventable illness, we did try to ascertain vaccine uptake during the baseline period.

"While it is likely that vaccination rates were suboptimal in this population, the percentages observed may be an underestimate due to lack of billing claims for specific vaccines, if, for example, an individual was vaccinated at a place of work or paid out of pocket," she noted.

Increasing rheumatologist involvement

"We identified a higher risk of acute care use for vaccine-preventable illnesses among individuals who are Black, compared to White, and a lower risk among individuals with higher versus lower outpatient care utilization," Dr. Feldman said. "With the known disparities in care and outcomes among individuals with lupus, further efforts are needed to improve access to high-quality outpatient care for the most vulnerable populations.

"Recommendations for vaccinations should be a routine part of care for SLE patients, and increasingly, this is the case. Efforts are being made to incorporate alerts and reminders in electronic medical record systems, which may help increase vaccine uptake," she added.

"Over the study period [2000-2010], we observed a decrease in the incidence of acute care use for vaccine-preventable illnesses, and I suspect that rates have continued to decrease since then," Dr. Feldman said. "Rheumatologists have increased their efforts over the last several years to develop quality improvement initiatives to increase influenza and pneumococcal vaccine uptake. However, other vaccinations that are not routinely provided to all patients and may be less readily available in a rheumatology clinic, such as the HPV and hepatitis B vaccines, still require additional efforts. We certainly know that disparities still exist by race/ethnicity and by socioeconomic status, and work is still needed to ensure that the most vulnerable patients have access to essential preventive care."

Image credit: Stefan Cristian Cioata/Moment/Getty Images

Additional research is needed to specifically examine vaccine uptake in recent years to better identify disparities and gaps in care. Such research "would allow for the development of targeted interventions to help reduce disparities in potentially avoidable adverse outcomes," she said.

The study was supported by grants from the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Dr. Feldman disclosed that she serves in unpaid positions on the board of directors of the American College of Rheumatology and on the Medical-Scientific Advisory Council of the Lupus Foundation of America. She receives research support from Pfizer unrelated to this work.