Splenectomy as a Destination: Improving Quality of Care Among Asplenic Veterans Through a Travel Clinic

doi:10.1016/j.amjmed.2017.01.024

The American Journal of Medicine

Volume 130, Issue 7, July 2017, Pages 856-861

https://doi.org/10.1016/j.amjmed.2017.01.024 Get rights and content

Abstract

Background

Asplenic patients are at risk for severe infections, but adherence to recommended preventive education and vaccination is poor. The goal of this study was to demonstrate that a targeted intervention can improve vaccination rates in a population of asplenic veterans.

Methods

Surgically asplenic patients actively receiving care in our health care system were identified via a database search. Patients were contacted via mailed letters and encouraged to attend an existing travel clinic with a new process designed for asplenic patients. In the clinic, patients were educated on the risks of asplenia and proper preventive precautions, a vaccination history was taken, and patients were administered any additional indicated vaccines.

Results

The database search yielded 113 patients; an additional 14 asplenic patients were identified and referred to the clinic by providers, and 2 were referred prior to planned splenectomy. Among all asplenic patients, the first-year referral rate to clinic was 38/129 (29%). During the first year of the intervention, there were increases in the rates of 3 of 4 recommended vaccinations: pneumococcal conjugate, 19% to 55% (P <.001); Haemophilus influenzae type B, 19% to 35% (P = .007); and meningococcal vaccine, 24% to 43% (P = .002). The pneumococcal polysaccharide vaccination rate increased from 91% to 93% (P = .62).

Conclusions

Targeted interventions can improve guideline-based care for asplenic patients. The creation of a clinic designed for asplenic patients led to increases in 3 of 4 recommended vaccinations. This strategy may be applicable to other health care systems with similar numbers of asplenic patients.

Section snippets

Methods

To identify asplenic patients at our facility, we queried the Corporate Data Warehouse, a centralized database for all patients cared for within the US Department of Veterans Affairs (VA) health care system. We identified patients 1) who had undergone a surgery containing “splenectomy” in the procedure name from January 1, 2000 through November 2, 2014 (the project start date), or 2) had the word “splenectomy” in their electronic problem list. Patients known to be deceased were excluded in this

Preintervention Data

We identified 168 patients, of whom 21 had undergone splenectomy at the Durham VA Medical Center, and 147 patients had prior splenectomy documented in their problem list. After removal of duplicate records (n = 6), patients found to be deceased on manual chart review (n = 4), and patients no longer cared for at the Durham VA (n = 45), 113 patients remained. These patients received an invitation to attend the clinic and an information pamphlet about asplenia (supplementary materials, available

Discussion

Our study demonstrates that this novel approach to improving the guideline-based care of asplenic patients was successful in increasing the rates of appropriate vaccination. Our approach built on the existing infrastructure of a travel clinic in order to meet the needs of this population without expenditure on additional personnel, training, or clinic space. The strategy was multidisciplinary by necessity, and involved collaboration among nurse practitioners, infectious diseases clinicians,

Acknowledgment

We wish to acknowledge the contributions of the following individuals, each of whom has given written permission to be included in this manuscript: Brian P. Hayes, MD, Department of Medicine, Durham Veterans Affairs Medical Center: Contributed to implementation of the intervention and reviewed manuscript; Rebekah Moehring, MD, Departments of Medicine, Duke University School of Medicine and Durham Veterans Affairs Medical Center: Contributed to implementation of the intervention and reviewed

References (13)

A.M. Lynch et al.
Overwhelming postsplenectomy infection
Infect Dis Clin North Am
(1996)
P. Nived et al.
Vaccination status and immune response to 13-valent pneumococcal conjugate vaccine in asplenic individuals
Vaccine
(2015)
L.G. Rubin et al.
Clinical practice. Care of the asplenic patient
N Engl J Med
(2014)
G.L. Cullingford et al.
Severe late postsplenectomy infection
Br J Surg
(1991)
K. Hansen et al.
Asplenic-hyposplenic overwhelming sepsis: postsplenectomy sepsis revisited
Pediatr Dev Pathol
(2001)
M.S. El-Alfy et al.
Overwhelming postsplenectomy infection: is quality of patient knowledge enough for prevention?
Hematol J
(2004)

There are more references available in the full text version of this article.

Cited by (8)

Adherence to vaccination guidelines of patients with complete splenectomy in Norway, 2008–2020
2023, Vaccine
The spleen is responsible for blood filtration and mounting an immune response against pathogens. In some people the spleen must be surgically removed because of traumatic events or oncological and hematological conditions. These patients are at higher risk of developing diseases caused by encapsulated bacteria throughout their lives. Thus, immunisations are advised for splenectomised persons to prevent infection caused by Streptococcus pneumoniae, Neisseria meningitidis and Haemophilus influenzae type b (Hib). This study assessed vaccination coverage (VC) among Norwegian patients with surgical asplenia. Using the Nomesco Classification of Surgical Procedures codes, patient information (age, sex, date of initial diagnosis and date of surgery) was acquired from the Norwegian Patient Registry. The National Immunization Register provided information on vaccination status and data of any subsequent invasive bacterial infections were obtained from the Norwegian Surveillance System for Communicable Diseases. From the total population of Norway, 3155 patients who had undergone complete splenectomy were identified. Of these, 914 (29.0%) had received at least one dose of pneumococcal conjugate vaccine (PCV), 1324 (42.0%) at least one dose of pneumococcal polysaccharide vaccine and 589 (18.7%) had received both. Only 4.2% of the patients had received two doses of a meningococcal ACWY conjugate vaccine, while 8.0% of 1467 patients splenectomised after 2014 had received at least two doses of a serogroup B meningococcal vaccine. The VC for Hib was 18.7%. Nearly all splenectomised children under the age of 10 were vaccinated with Hib and PCV as these vaccines are included in the childhood immunisation program. For all vaccines, VC decreased with age. Twenty-nine invasive bacterial infections were registered post-splenectomy in 25 patients. Vaccination according to national recommendations could have prevented at least 8 (28%) of these infections. Our study showed that efforts are required to increase VC of splenectomised individuals in Norway.
Meningococcal vaccination in patients with newly diagnosed asplenia in the United States
2021, Vaccine
Citation Excerpt :
Additionally, this survey finding also indicates that pediatricians may be more aware of the MenB high-risk recommendations compared to family physicians. In an attempt to improve vaccine coverage for asplenic patients, a US study invited veterans who had undergone splenectomy (identified via a database search) to a clinic where they received education about their infection risk; their vaccination history was taken; and vaccinations were offered [21]. This improved meningococcal vaccination rates from 24% (before the intervention) to 32% (among those who were invited but did not attend) or 90% (among those who attended) [21].
Patients with asplenia are recommended to receive meningococcal ACWY (MenACWY) and B (MenB) vaccines in the United States (US).
To examine uptake and time to receipt of meningococcal vaccines in newly diagnosed asplenia patients, and identify factors associated with vaccination.
For this retrospective database analysis, patients were identified from 1/1/2010 (MenACWY) or 1/1/2015 (MenB) through 3/31/2018 from an administrative claims database including commercially insured US patients with ≥1 inpatient or ≥2 outpatient claims with evidence of a new asplenia diagnosis (sickle cell disease was excluded); continuous enrollment for ≥12 months before and ≥6 months after the index date; and age ≥2 (MenACWY) or ≥10 (MenB) years. Co-primary outcomes were uptake and time to receipt of ≥1 dose, separately for MenACWY and MenB, by Kaplan–Meier analysis. Cox proportional hazards regression models were used to identify characteristics associated with vaccination.
Among 2,273 and 741 patients eligible for the MenACWY and MenB analyses, respectively, 28.1% and 9.7% received MenACWY and MenB in the first 3 years after a new asplenia diagnosis. Patients were more likely to receive meningococcal vaccines if they had received pneumococcal vaccines (MenACWY: hazard ratio [HR] 26.02; 95% confidence interval [CI] 21.01–32.22; MenB: HR 3.89; 95% CI 2.07–7.29) or attended ≥1 well-care visit (MenACWY: HR 6.63; 95% CI 4.84–9.09; MenB: HR 11.17; 95% CI 3.02–41.26).
Meningococcal vaccination rates among newly diagnosed asplenia patients were low, highlighting the need to educate providers about the recommendations for high-risk conditions and ensure healthcare access for vulnerable patients.
Efficacy of a novel patient-focused intervention aimed at increasing adherence to guideline-based preventive measures in asplenic patients: the PrePSS trial
2023, Infection
The Impact of Standardized Infectious Diseases Consultation on Postsplenectomy Care and Outcomes
2022, Open Forum Infectious Diseases
Preventing infections in children and adults with asplenia
2020, Hematology (United States)
Prevention of infection in asplenic adult patients by general practitioners in France between 2013 and 2016
2020, BMC Family Practice

View all citing articles on Scopus

: Funding: This study was unfunded.

: Conflict of Interest: All authors have no conflicts of interest to disclose.

: Authorship: APM had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. All authors had full access to the data, were directly involved in writing the manuscript, and have approved this final version.

View full text

Published by Elsevier Inc.

Clinical research studySplenectomy as a Destination: Improving Quality of Care Among Asplenic Veterans Through a Travel Clinic

Abstract

Background

Methods

Results

Conclusions

Section snippets

Methods

Preintervention Data

Discussion

Acknowledgment

Infect Dis Clin North Am

Vaccine

Clinical practice. Care of the asplenic patient

N Engl J Med

Severe late postsplenectomy infection

Br J Surg

Asplenic-hyposplenic overwhelming sepsis: postsplenectomy sepsis revisited

Pediatr Dev Pathol

Overwhelming postsplenectomy infection: is quality of patient knowledge enough for prevention?

Hematol J

Clinical research study
Splenectomy as a Destination: Improving Quality of Care Among Asplenic Veterans Through a Travel Clinic