Improving Adult Immunizations in the Primary Care Setting
Improving Adult Immunizations in the Primary Care Setting
From the 17 practices who participated in the program, a total of 1190 patient chart abstractions were submitted. Half of the practices had an electronic medical record (EMR) system in their practice at pre-intervention, and 64.7% had an EMR at post-intervention. Pre- and post-intervention patient groups did not differ significantly in race, age, ethnicity, or gender. Most of the patients were White, non-Hispanic, and had Medicare or commercial insurance. More than half of the patients (57.8% pre-intervention, 58.7% post-intervention) had hypertension, and more than a quarter had diabetes (29.1% pre-intervention, 28.6% post-intervention; Table 1). Aside from aggregate pre- and post-intervention comparisons, the data were evaluated at the individual practice level before and after intervention to ensure there was no difference in patient populations at both time points that would affect immunization rates.
The denominator for all reported survey data was 17. Statistically significant improvement was found in physician self-reported immunization rates for pertussis (26.47% pre-intervention, 54.41% post-intervention; P ≤ .01) and tetanus (50.00% pre-intervention, 66.18% post-intervention; P ≤ .05). The number of physicians who reported using the latest CDC adult immunization schedule on an annual basis increased significantly (52.9% pre-intervention, 88.2% post-intervention; P ≤ .02). There was a statistically significant increase in the number of physicians who reported all staff received their annual flu shot (72.06% pre-intervention, 89.71% post-intervention; P ≤ .006). Similarly, there was a statistically significant improvement seen in the number of physicians who reported that their staff was up to date with Td/Tdap vaccinations (63.24% pre-intervention, 79.41% post-intervention; P ≤ .05).
Data were analyzed to examine if patient vaccination rates for indicated conditions changed from before to after intervention (Table 2 and Table 3). Results showed statistically significant improvements in pneumococcal vaccinations for patients with chronic lung disease (73.8%, 89.7%; P ≤ .01), diabetes (55.6%, 68.8%; P ≤ .01), and heart disease (56.3%, 86.3%; P ≤ .01). Overall vaccination rates statistically improved for pneumococcal (52.2% pre-intervention, 74.5% post-intervention; P ≤ .01), Td/Tdap (45.6% pre-intervention, 55.0% post-intervention; P ≤ .01), and herpes zoster (12.3% pre-intervention, 19.3% post-intervention; P ≤ .01).
We examined differences pre- and post-intervention for office visits at which the vaccination was administered and found several statistically significant findings. (For each vaccination, the numerator was the number of patients vaccinated during the type of office visit; the denominator consisted of the total number of patients seen at that type of office visit, with the exclusion of those patients for whom the vaccination was noted by the physician as not indicated.) There was an increase from pre- to post-intervention (3.3% pre-intervention, 62.7% post-intervention) in hepatitis B vaccinations given at annual visits (P ≤ .01). A statistically significant improvement was seen in physicians administering the influenza vaccination at annual visits from 7.5% before intervention to 26% after intervention (P ≤ .01). In addition, there were statistically significant improvements seen in physicians administering the Td/Tdap vaccination at annual visits (from 20.1% pre-intervention to 41.7% post-intervention; P ≤ .01) and the herpes zoster vaccinations given at annual visits (10.3% pre-intervention, 35.3% post-intervention; P ≤ .04). Statistically significant improvements were seen in physicians discussing herpes zoster vaccination with their patients, from 23.2% to 43.3% (P ≤ .01). Lastly, a statistically significant improvement was seen across the 2 data points regarding physicians discussing the pneumococcal vaccination with their patients (19.9% pre-intervention, 43.0% post-intervention; P ≤ .01).
The association between practice vaccination rates and their quality improvement goals were also analyzed, with results showing that goals precipitated different improvements for various immunizations (Table 4). Practices that focused on increasing influenza vaccination rates had statistically significant improvements in influenza (66.1% pre-intervention, 77.9% post-intervention; P ≤ .01), pneumococcal (54.4% pre-intervention, 82.8% post-intervention; P ≤ .01), and Td/Tdap (39.2% pre-intervention, 56.0% post-intervention; P ≤ .01). Practices with this goal had influenza and pneumococcal rates that exceeded national immunizations rates (68.8%, 65.6%, respectively). Practices that focused on increasing pneumococcal vaccination rates had statistically significant and higher than nationally reported rates in influenza (61.3% pre-intervention, 71.3% post-intervention; P ≤ .01) and pneumococcal (46.3% pre-intervention, 73.2% post-intervention; P ≤ .01) vaccinations. Practices focusing on better immunization documentation saw statistically significant improvements for influenza (48.4% pre-intervention, 59.6% post-intervention; P ≤ .04), pneumococcal (29.5% pre-intervention, 58.3% post-intervention; P ≤ .01), and Td/Tdap (27.6% pre-intervention, 53.5% post-intervention; P ≤ .01). Practices that focused on patient education for vaccinations saw statistically significant improvements for pneumococcal (51.2% pre-intervention, 77.2% post-intervention; P ≤ .01) and Td/Tdap (42.7% pre-intervention, 64.0% post-intervention; P ≤ .01).
Self-reported increases in immunization rates were consistent with practice data findings. Overall, results indicated that physicians improved their immunization practices (i.e., seeking out CDC adult immunization schedule, staff vaccination rates) using the team approach. Indicated vaccines for various disease conditions improved as well, evidenced by the practical application of the CDC adult immunization schedule to their practice. Additionally, practice quality improvement goals had an effect on which vaccinations improved, except for the influenza vaccination, which improved significantly regardless of the quality improvement goal set by the practice.
Results
From the 17 practices who participated in the program, a total of 1190 patient chart abstractions were submitted. Half of the practices had an electronic medical record (EMR) system in their practice at pre-intervention, and 64.7% had an EMR at post-intervention. Pre- and post-intervention patient groups did not differ significantly in race, age, ethnicity, or gender. Most of the patients were White, non-Hispanic, and had Medicare or commercial insurance. More than half of the patients (57.8% pre-intervention, 58.7% post-intervention) had hypertension, and more than a quarter had diabetes (29.1% pre-intervention, 28.6% post-intervention; Table 1). Aside from aggregate pre- and post-intervention comparisons, the data were evaluated at the individual practice level before and after intervention to ensure there was no difference in patient populations at both time points that would affect immunization rates.
The denominator for all reported survey data was 17. Statistically significant improvement was found in physician self-reported immunization rates for pertussis (26.47% pre-intervention, 54.41% post-intervention; P ≤ .01) and tetanus (50.00% pre-intervention, 66.18% post-intervention; P ≤ .05). The number of physicians who reported using the latest CDC adult immunization schedule on an annual basis increased significantly (52.9% pre-intervention, 88.2% post-intervention; P ≤ .02). There was a statistically significant increase in the number of physicians who reported all staff received their annual flu shot (72.06% pre-intervention, 89.71% post-intervention; P ≤ .006). Similarly, there was a statistically significant improvement seen in the number of physicians who reported that their staff was up to date with Td/Tdap vaccinations (63.24% pre-intervention, 79.41% post-intervention; P ≤ .05).
Patient Chart Abstraction Data
Data were analyzed to examine if patient vaccination rates for indicated conditions changed from before to after intervention (Table 2 and Table 3). Results showed statistically significant improvements in pneumococcal vaccinations for patients with chronic lung disease (73.8%, 89.7%; P ≤ .01), diabetes (55.6%, 68.8%; P ≤ .01), and heart disease (56.3%, 86.3%; P ≤ .01). Overall vaccination rates statistically improved for pneumococcal (52.2% pre-intervention, 74.5% post-intervention; P ≤ .01), Td/Tdap (45.6% pre-intervention, 55.0% post-intervention; P ≤ .01), and herpes zoster (12.3% pre-intervention, 19.3% post-intervention; P ≤ .01).
We examined differences pre- and post-intervention for office visits at which the vaccination was administered and found several statistically significant findings. (For each vaccination, the numerator was the number of patients vaccinated during the type of office visit; the denominator consisted of the total number of patients seen at that type of office visit, with the exclusion of those patients for whom the vaccination was noted by the physician as not indicated.) There was an increase from pre- to post-intervention (3.3% pre-intervention, 62.7% post-intervention) in hepatitis B vaccinations given at annual visits (P ≤ .01). A statistically significant improvement was seen in physicians administering the influenza vaccination at annual visits from 7.5% before intervention to 26% after intervention (P ≤ .01). In addition, there were statistically significant improvements seen in physicians administering the Td/Tdap vaccination at annual visits (from 20.1% pre-intervention to 41.7% post-intervention; P ≤ .01) and the herpes zoster vaccinations given at annual visits (10.3% pre-intervention, 35.3% post-intervention; P ≤ .04). Statistically significant improvements were seen in physicians discussing herpes zoster vaccination with their patients, from 23.2% to 43.3% (P ≤ .01). Lastly, a statistically significant improvement was seen across the 2 data points regarding physicians discussing the pneumococcal vaccination with their patients (19.9% pre-intervention, 43.0% post-intervention; P ≤ .01).
The association between practice vaccination rates and their quality improvement goals were also analyzed, with results showing that goals precipitated different improvements for various immunizations (Table 4). Practices that focused on increasing influenza vaccination rates had statistically significant improvements in influenza (66.1% pre-intervention, 77.9% post-intervention; P ≤ .01), pneumococcal (54.4% pre-intervention, 82.8% post-intervention; P ≤ .01), and Td/Tdap (39.2% pre-intervention, 56.0% post-intervention; P ≤ .01). Practices with this goal had influenza and pneumococcal rates that exceeded national immunizations rates (68.8%, 65.6%, respectively). Practices that focused on increasing pneumococcal vaccination rates had statistically significant and higher than nationally reported rates in influenza (61.3% pre-intervention, 71.3% post-intervention; P ≤ .01) and pneumococcal (46.3% pre-intervention, 73.2% post-intervention; P ≤ .01) vaccinations. Practices focusing on better immunization documentation saw statistically significant improvements for influenza (48.4% pre-intervention, 59.6% post-intervention; P ≤ .04), pneumococcal (29.5% pre-intervention, 58.3% post-intervention; P ≤ .01), and Td/Tdap (27.6% pre-intervention, 53.5% post-intervention; P ≤ .01). Practices that focused on patient education for vaccinations saw statistically significant improvements for pneumococcal (51.2% pre-intervention, 77.2% post-intervention; P ≤ .01) and Td/Tdap (42.7% pre-intervention, 64.0% post-intervention; P ≤ .01).
Self-reported increases in immunization rates were consistent with practice data findings. Overall, results indicated that physicians improved their immunization practices (i.e., seeking out CDC adult immunization schedule, staff vaccination rates) using the team approach. Indicated vaccines for various disease conditions improved as well, evidenced by the practical application of the CDC adult immunization schedule to their practice. Additionally, practice quality improvement goals had an effect on which vaccinations improved, except for the influenza vaccination, which improved significantly regardless of the quality improvement goal set by the practice.