Caroline Helwick

June 22, 2015

NEW ORLEANS — For patients awaiting liver transplantation, rates of hepatitis A and hepatitis B vaccination improved significantly after the implementation of nurse-led an intervention.

"We improved from a baseline rate of only 45% to 87%," reported Shari Perez, DNP-C, from the Mayo Clinic in Scottsdale, Arizona.

In fact, patients were nearly 9.5 times more likely to complete the vaccination series after the system was implemented, Perez reported here at the American Association of Nurse Practitioners 2015 National Conference.

When cirrhotic patients are not immune to the hepatitis A or hepatitis B virus, they can develop life-threatening acute viral hepatitis. A cirrhotic patient who receives an organ from a hepatitis B core antibody-positive donor will require hepatitis B antiviral therapy for at least 1 year, and sometimes for life.

"Completing vaccination prior to liver transplant helps minimize the risk for acute or chronic disease and reduces post-transplant medication costs," Perez told Medscape Medical News. "The average cost of antiviral therapy is more than $1300 a month."

Perez and her colleagues wanted to improve completion rates of the series of hepatitis A and B vaccinations in patients on the list for liver transplantation at their institution. Their specific goal was to increase the administration of dose 1 by 10% and doses 2 and 3 rates by 20%.

The intervention involved a vaccine tracking system using the department database, improved order entry for required vaccines, better vaccine-scheduling practices, patient mail-in vaccination cards, and an electronic medical record patient-flagging system for providers.

They compared vaccination rates in 44 patients listed for liver transplantation after the intervention and 57 patients listed before the intervention.

Overall vaccination completion rates were better after the intervention.

Completion rates of the hepatitis B series "improved by 59%, potentially decreasing the need for costly long-term antiviral therapy," Perez reported.

Table. Outcomes Rates Before and After the Intervention

Dose Preintervention, % Postintervention, % Relative Increase, % Odds Ratio P Value
1 85.4 95.4 11.7 2.33 0.4718
2 55.5 95.4 72.2 11.90 <0.001
3 40.7 86.3 112.0 10.7 <0.001
All 44.7 87.2 94.7 9.55 < 0.001


Perez credits the tracking and patient-flagging systems with substantially improving rates of series completion.

"Relying on RN coordinators to remember to ask about vaccination or to look in the vaccination tab is difficult," she explained. "The research shows that the more you use EMR for reminders, the better you do."

The duration of the intervention was not long enough to assess the effectiveness of the mail-in vaccination cards or the patient-flagging system on vaccination completion rates, she noted.

Wider Applications

This system could be applicable beyond just the transplant population, said Neva Lipscomb, NP-C, from a public health clinic run by Louisiana State University in Baton Rouge.

"We see numerous patients with hepatitis C, and we try to immunize them with hepatitis A and B vaccines as soon as we see them in the clinic. We are hoping to prevent even worse liver dysfunction later," she told Medscape Medical News.

"We do a hepatitis panel to see if they have had hepatitis A or B, and if they are not already immune we start the series of immunizations. We try to follow-up with phone calls and so forth, but some of them fall off. A system to help track patients with liver disease is definitely needed," Lipscomb explained.

Ms Perez and Ms Lipscomb have disclosed no relevant financial relationships.

American Association of Nurse Practitioners (AANP) 2015 National Conference: Abstract NP155. Presented June 10, 2015.


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