Sandra Yin

May 15, 2012

May 15, 2012 (Baltimore, Maryland) — Pediatric and family medicine practices that applied a bundle of evidence-based strategies saw significant increases in childhood influenza vaccination rates, according to interim results presented here at the National Foundation for Infectious Diseases (NFID) 15th Annual Conference on Vaccine Research.

"Eight of 10 practices reached more than a 100% increase in the number of doses given," said lead investigator Richard Zimmerman, MD, MPH, professor of family medicine and clinical epidemiology at the University of Pittsburgh, Pennsylvania.

Influenza attack rates are 10% to 20% annually. Influenza accounts for 10% to 15% of office visits for children younger than 5 years, and the same percentage of emergency department visits during flu season. Despite the disease burden and the recommendation that all children 6 months to 18 years be vaccinated, vaccination rates have been modest.

The researchers used a multifaceted approach to see if rates could be improved. They developed a 4-part evidence-based toolkit and introduced it to practices to boost vaccination rates.

The 4 pillars of the toolkit are:

  • Convenient influenza vaccination services (such as express vaccination). Researchers allowed the offices to design the best express services. Some have factory-style vaccinations, in which a suburban office closes down except for vaccinations, so people are in and out in 10 minutes. In the inner city, it might be a daytime no-appointment-necessary express vaccination service.

  • Patient notification about availability of convenient programs and vaccination recommendations. If the patients don't know about the convenient services, they can't come. Dr. Zimmerman said he thinks that physician recommendation is powerful. The message researchers want practices to get out is that you can get vaccinated; this is how you can do it conveniently, he added. Auto-dialer phone calls are one way to notify patients.

  • Enhanced office vaccination systems, such as systematic assessment by electronic medical records (EMRs) or staff workflow coupled with standing orders. An EMR might turn on a best-practice alert that doesn't vanish until the child is vaccinated. Some practices encourage staff to check whether the child's vaccinations are up to date as part of the vital signs examination.

  • Motivation with an office immunization champion tracking progress toward a set goal, and comparison with other practices.

The researchers originally wanted to improve vaccination rates at each site by at least 25% over the previous year. Sites responded so well to the intervention that researchers revised the goals upward. Ultimately, just 1 practice of the 10 in year 1 of the intervention didn't hit its goals.

The toolkit was tested in a randomized cluster trial of 20 sites in which the primary care office was the site of randomization. In year 1 of the 2-year study, 10 practices applied the intervention, which generated the interim results presented here.

Of the first set of 10 that used the toolkit, 6 were nonacademic pediatric practices in a collaborative network, 2 were academic pediatric practices serving disadvantaged populations, 1 was a family medicine residency program that served a disadvantaged population, and 1 was a nonacademic suburban family medicine practice. All 10 practices use the same EMR system.

The researchers expanded the vaccination season with a starter supply of vaccine in August. To ensure the vaccine arrived at selected sites early, they got help from the state Vaccine for Children program. They also got a free starter supply from a manufacturer to ensure that disadvantaged children could be vaccinated in late August.

Each week, researchers pulled the number of children seen, the number vaccinated, and the number not vaccinated from EMRs. From there, they calculated percentage vaccinated and percentage of presumed missed opportunities. Weekly reports sent to sites included missed opportunities, cumulative total vaccines given, and the rankings of the sites, so they could compare performance.

"When you start looking at a whole week of patients and you see the number of people, and you compare one office to another, you begin to get a sense of which practices are really using their opportunities to vaccinate," noted Dr. Zimmerman.

During debriefings, one message came through loud and clear. "They're saying the early start to the vaccination season made all the difference," said Dr. Zimmerman. "That was a really strong message."

"Despite there having been a universal influenza recommendation now for the past few years, rates for influenza immunization among children remain suboptimal," Susan Rehm, MD, medical director at the NFID, who moderated the session, told Medscape Medical News. The advantage of the 4-step toolkit is that it's simple. It's applicable to a variety of different practices, she said. "And in ideal circumstances, it allows for data tracking so that people can benchmark their practices against other practices. People often like to rise to the occasion."

The Centers for Disease Control and Prevention are funding this study. Dr. Zimmerman reports serving as an advisor or consultant for MedImmune and receiving grants for clinical research from MedImmune and Merck & Co. Dr. Rehm reports serving as an advisor or consultant for Merck & Co. and Pfizer, and as a speaker for Genentech.

National Foundation for Infectious Diseases (NFID) 15th Annual Conference on Vaccine Research: Session S11. Presented May 7, 2011.

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