Simple Alert Increases Uptake of Prenatal Tdap Vaccine

Tara Haelle

April 29, 2018

AUSTIN, Texas — A pop-up reminder in electronic medical records increased uptake of the prenatal Tdap vaccine by more than a third, a new study found.

"Preintervention vaccination rates were very low — less than 50% — and that is consistent with national rates over the past few years," said lead author Katie Keepers, MD, a resident at the University of Kansas Medical Center in Kansas City.

"We thought this was a simple intervention to make a significant impact for my patients," she told Medscape Medical News here at American College of Obstetricians and Gynecologists (ACOG) 2018 Annual Meeting, where the research was presented.

The Centers for Disease Control and Prevention (CDC) recommends that women receive a Tdap vaccination between 27 and 36 weeks' gestation in every pregnancy, so that the fetus receives a transfer of maternal antibodies against pertussis. The highest risk for death from pertussis is in a child's first 2 months, but infants do not receive their first vaccination against pertussis until they are 2 months old.

Rates of prenatal Tdap vaccination have lagged nationally since the recommendation was made in October 2012, despite evidence that the vaccine does protect infants against pertussis infection ( Clin Infect Dis. 2017;65:1977-1983). However, coverage has risen from 27.0% in 2014 to 48.8% in 2016, according to the CDC.

For the current study, a best practice advisory pop-up message was created for the hospital clinic's electronic medical record system to remind providers of the CDC recommendation. The provider was then given the option to order the vaccine directly from the message screen or to acknowledge the reason for not doing so (Patient Declines, Other [comment], Not Indicated).

The pop-up could be dismissed, but unless the physician selected one of the options, it would continue to appear at every visit for all patients between 27 and 36 weeks of pregnancy.

It took a few months to design the pop-up because the researchers wanted to be sure it was functional by linking directly to orders, said Keepers.

"We all know you should be vaccinating, but we have a large resident population," she explained. "I think it's nice that it will come up for nurses too, when they check in the patient, so the nurse can say, 'Your doctor might talk to you about Tdap today.' I think it increased a lot of communication during the visit for multiple providers."

The researchers then reviewed charts for all deliveries between September and December 2016, before the pop-up implementation, and deliveries between September and December 2017, after implementation, to compare Tdap vaccine uptake.

They compared the same 4 calendar months to reduce the likelihood that seasonality would influence rates, Keepers told Medscape Medical News.

In the 2016 study period, just 44.6% of 531 patients between 27 and 36 weeks' gestation received a Tdap vaccination. In the 2017 period, after implementation of the alert, coverage was 60.3% of 574 patients (P < .0001). No differences in patient characteristics were found between those who did and did not receive the vaccine.

The average patient age was 28.1 years preimplementation and 28.8 years postimplementation. Nulliparity was also similar: 36.2% in 2016 and 37.2% in 2017. There were too many variables for the researchers to be able to compare differences in insurance status or other payer factors, said Keepers.

Biggest Change in First Month

The first month postimplementation saw the biggest change in vaccine uptake, but that was also the month with the lowest uptake in 2016.

"I thought it was really interesting that the first month was so much higher, but I think that first month might have been an outlier," Lois Brustman, MD, a professor of obstetrics, gynecology and reproductive science at the Icahn School of Medicine in New York City, told Medscape Medical News.

The average increase in vaccine uptake across all the months is what is most important, she added.

Tronya Hawkins, MD, from St. Vincent's Women's Hospital in Indianapolis, Indiana, said she also was curious about the bigger improvement in that first month.

"I'm impressed that the screener took the opportunity to evaluate uptake before, the fact that they were able to implement in their [electronic medical records], and that there was a significant improvement after the intervention," Hawkins told Medscape Medical News.

"My question, though, would be what happened after the first month?" She wondered whether the uptake remain consistent after the months reported by the study, whether the pop-ups continued, and whether anything else changed.

Keeper told Medscape Medical News that she suspects pop-up fatigue may explain the tapering off of rates after the first month.

Maram Said, DO, from St. Vincent's Carmel in Indianapolis, agreed: "People might start to exit without even looking at it," she told Medscape Medical News.

Overall, however, she found it a "clever and easy intervention" to bring up vaccination rates.

Need for More Patient Education

It was a well-designed study with a worthwhile quality improvement implementation that could be implemented elsewhere, added Brustman.

"I think it's a very easy intervention for other people to do, no matter how much more improvement you get," she said, but she would like to see even greater improvement.

"It shows that we need to educate more, so now you have to say, How do you make it better?" she told Medscape Medical News.

Perhaps a second intervention could involve providing patients with a pamphlet or spending extra time educating patients about the rationale for the vaccine.

"I think women are reluctant to take it, and that you really do have to spend the time to explain to them in lay terms why they're getting the vaccine," said Brustman.

"There's always going to be a percentage of women who are going to say no," she said, but she has found that taking an extra 5 minutes to explain the physiology behind the vaccine often shifts women's initial reluctance into acceptance.

Vaccines are hard to sell nowadays. Dr Tronya Hawkins

Hawkins agreed with the need for more patient education, but added that she would like to see more resources for providers to help them in educating women.

"Vaccines are hard to sell nowadays," given the litigiousness of society and people's fears about serious adverse events, she told Medscape Medical News. "I think it's more about patients being misinformed or educated against what I'm recommending that is a barrier, more so than, or as much as, [providers] not remembering to offer it."

Hawkins would like to see more information for providers from the CDC that explains how long protection lasts in infants and offers strategies for speaking to pregnant women about the vaccine.

"I do think this is a great way to get more women vaccinated, and we definitely talk about it, even with their spouses," she said. "But we definitely don't get every patient every time, and that's what we're striving for."

The study did not use external funding. Keepers, Hawkins, Said, and Brustman have disclosed no relevant financial relationships.

American College of Obstetricians and Gynecologists (ACOG) 2018 Annual Meeting: Abstract 8L. Presented April 28, 2018.

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