Pneumococcal Vaccination Recommendation and Completion Rates Among Inflammatory Bowel Disease Patients Within a Large Academic Health System

Abstract

Patients with inflammatory bowel disease (IBD) are at increased risk for pneumonia and if hospitalized, have a higher mortality. Based on the Centers for Disease Control (CDC) guidelines published in 2012, vaccination with both the pneumococcal polysaccharide vaccine (PPSV23) and the pneumococcal conjugate vaccine (PCV13) is recommended for IBD patients who are receiving immunosuppressive treatment (steroids, immunomodulators, and/or biologics). Previous studies have shown low pneumococcal vaccination rates among IBD patients, yet few have assessed which specific vaccines are recommended and administered. Thus, we determined the pneumococcal vaccination recommendation and administration rates among IBD patients on immunosuppressive therapy in a large academic health system. We identified a cohort of patients aged ≥ 18 years with an IBD diagnosis based on ICD-9 and 10 codes seen by any gastroenterologist within our health system between 1/1/2014 and 9/4/2019. We performed a retrospective chart review to confirm IBD diagnosis and longitudinal care in a random sample of patients. Data abstraction included patient demographics, provider history, medications and disease characteristics. The primary outcome was the rate of documented vaccination recommendation by providers; the secondary outcome was rate of administration of the vaccines, calculated as the proportion of patients eligible for the vaccines who received the appropriate vaccines. We performed multivariable logistic regression to determine factors associated with receipt of any pneumococcal vaccine in patients on immunosuppressive medications. Our cohort included 253 IBD patients (median age 43 years; 55% female; 70% Caucasian; 83% privately insured) (Table 1). Eighty-seven percent of patients had a primary care physician (PCP) and 78% were on immunosuppressive medications at any time during the study period. Of the 197 immunosuppressed patients, 56% had any pneumococcal vaccination recommended and 38% had recommendations for both PPSV23 and PCV13. In addition, 40% received any pneumococcal vaccine and 16% received both vaccines (Image 2). In the multivariable analysis, age [adjusted odds ratio (aOR) 1.03, 95% confidence interval (CI): 1.01-1.05)] and having a PCP (aOR 3.84, 95% CI: 1.12-13.16) were associated with receipt of any pneumococcal vaccine in immunosuppressed patients, after adjusting for gender, race, insurance, disease activity, and time seen in our GI clinics. In our healthcare system, recommendation and receipt of both PPSV23 and PCV13 in IBD patients on immunosuppression is low. Older patients and those with a PCP were more likely to receive any pneumococcal vaccine. Further investigation of physician and patient knowledge of pneumococcal vaccination indications and barriers to receipt of vaccines is necessary to improve vaccination rates.Table-1Demographics of Total Cohort and Multivariable Analysis of Immunosuppressed PatientsMedian (IQR) or n (%)aOR (95% CI)∗Adjusted models for patients on immunosuppression (n = 197) included: age, gender, race, insurance, disease activity, PCP status, time seen in our GI clinicsTotal number of patients253 (100)Age (years)43 (27)1.03 (1.01-1.05)Sex Female139 (55)0.80 (0.42-1.51) Male114 (45)RefBMI (kg/m2)24.8 (5.4)Race White176 (69.6)Ref Asian12 (4.7)0.60 (0.28-1.28)ˆNon-White vs. White race Black3 (1.2) Other45 (17.8) Unknown17 (6.7)Primary insurance type Private210 (83)Ref Medicare29 (11.5)1.23 (0.46-3.31)¥Medicare/Medicaid/Other vs. Private insurance Medi-Cal/Medicaid4 (1.5) Other3 (1.2) No insurance or unknown7 (2.8)0.59 (0.06-5.62)¶No insurance vs. Private insuranceUrban residence251 (99.2)ASA physical status ASA 137 (14.6) ASA 2181 (71.5) ASA 322 (8.7) ASA 41 (0.4) Unknown12 (4.7)Provider historyTime seen in our GI clinics (years)3 (4)0.97 (0.90-1.05)Primary care provider219 (86.6)3.84 (1.12-13.16)†Ref: No PCPPrimary care provider at our institution129 (51)Disease characteristicsType of IBD Crohn’s disease115 (45.5) Ulcerative colitis138 (54.6)Duration of disease (years)11 (13)Active disease at last GI visit85 (33.6)0.96 (0.49-1.88)€Ref: Inactive diseaseOn immunosuppressive medication(s) at any time197 (77.9)On immunosuppressive medication(s) at last GI visit139 (55)Abbreviations aOR = Adjusted odds ratio, CI = Confidence interval, IQR = Interquartile range, BMI = Body mass index, ASA = American Society of Anesthesiologists, IBD = Inflammatory bowel disease, GI = Gastroenterology, PCP = Primary care physician, Ref = Reference group∗ Adjusted models for patients on immunosuppression (n = 197) included: age, gender, race, insurance, disease activity, PCP status, time seen in our GI clinicsˆ Non-White vs. White race¥ Medicare/Medicaid/Other vs. Private insurance¶ No insurance vs. Private insurance† Ref: No PCP€ Ref: Inactive disease Open table in a new tab Abbreviations aOR = Adjusted odds ratio, CI = Confidence interval, IQR = Interquartile range, BMI = Body mass index, ASA = American Society of Anesthesiologists, IBD = Inflammatory bowel disease, GI = Gastroenterology, PCP = Primary care physician, Ref = Reference group