Single center study for improving hepatitis a and b immunity in veterans with cirrhosis

ABSTRACT

Introduction: Patients with cirrhosis should be immunized against hepatitis A (HAV) & hepatitis B (HBV) as they are high risk for decompensation if infected. Baseline data at the Atlanta VA hepatology clinics demonstrated 75% of veterans with cirrhosis were immune to HAV and 44% to HBV. One fourth of visits failed to address hepatitis vaccines, and 60% of missed opportunities were from providers not discussing it. Our aim was to reduce missed opportunities to initiate HAV and HBV vaccination to <and to confirm immunity with serologies to < over 6 months in the Atlanta VA hepatology clinics. Methods: A process map identifying steps to obtain a vaccine and Pareto charts quantifying rates of commonly identified barriers were used to implement Plan-Do-Study-Act (PDSA) cycles. Approximately every 10th chart was sampled, and P charts were created to assess the average missed opportunity rate before and after our QI initiatives. Results: PDSA 1 focused on educating providers on the importance of vaccination, sharing the baseline data, and instructing how to order vaccines. For PDSA 2, the liver pharmacist monitored the vaccine queue daily to ensure that orders remained active. PDSA 3 involved a “quality inspection” by the attending hepatologist, who alerted the provider if vaccination was not addressed but was warranted. The last PDSA included creating a “Liver Passport” for the veteran that had personalized vaccination, hepatocellular screening, and esophageal variceal screening recommendations. The overall average missed opportunities for HAV & HBV vaccination and serologic confirmation testing decreased from 41% to 29% after four PDSA cycles. Separately, mean missed opportunities for initiating HAV & HBV vaccination decreased from 25% to 19% and assessing immunity with HAV & HBV serologies declined from 16% to 10%.Conclusion: Lack of in-person visits during the COVID-19 pandemic was a significant study limitation early on. Nevertheless, the national discussion surrounding COVID-19 vaccines provided a springboard for our QI initiatives to increasingly address HAV & HBV vaccines and immunity within a short time frame. Future aims are ≥HAV and HBV immunity and addressing all other vaccines recommended in patients with cirrhosis.