Bella Vogt. SEARCH Student Project. November 2011

Transcription

1 Analysis and Performance Follow Up Project: Compliance Rates of the 23-Valent Pneumococcal Polysaccharide Vaccine for At-Risk Patients at Optimus Health Care s Park City Primary Care Center: Has Improvement Been Made? Bella Vogt SEARCH Student Project November 2011

2 SEARCH Program Student/Resident Experiences And Rotations in Community Health Initiative of the Community Health Center Association of Connecticut Mission: Assist CT s federally qualified health centers in providing high quality health care and social services to the area s underserved populations Bring students from different health professions into underserved areas to get experience in hopes of turning them into culturally competent providers

3 Pneumococcal Disease Streptococcus pneumoniae is a gram positive diplococcal species that is a common causative agent of acute bacterial pneumonia, meningitis and otitis media S. pneumoniae is a human pathogen with transmission occurring via respiratory droplets and autoinoculation in persons carrying this bacteria in the upper respiratory tract. There are roughly 175,000 hospitalizations each year in the United States for acute bacterial pneumonia caused by S. pneumonia and over 50,000 cases of S. pneumonia bacteremia. S. pneumonia is also a leading cause of bacterial meningitis in children in the United States. Clinical symptoms are more severe in children and elderly individuals and there is a high morbidity and mortality rate in this population Pneumococcal bacteremia has up to 60% mortality rate in the elderly population Pneumococcal meningititis has up to 80% mortality rate in the elderly population

4 Pneumococcal Vaccine (PPSV 23 /Pneumovax) PNEUMOVAX 23 is a vaccine indicated for active immunization for the prevention of pneumococcal disease caused by the 23 serotypes contained in the vaccine PNEUMOVAX 23 is approved for use in persons 50 years of age or older and persons aged 2 years who are at increased risk for pneumococcal disease. CDC guidelines recommend vaccination to populations at increased risk illness of developing a serious illness if infected by pneumococcal bacterium

5 CDC Recommendations Initial Vaccination Recommendations Adults 65 years and older Anyone 2-64 years with a long term health problem Anyone 2-64 years who has a disease or condition that lowers the body s resistance to infection Anyone 2-64 years who is taking a drug or treatment that lowers the body s resistance to infection Any adult years of age who is a smoker or has asthma Residents of nursing homes or long term care facilities Revaccination Recommendations A second dose is recommended: For those age 65 and older who got their 1 st dose when they were younger than 65 and it has been more than 5 years since their 1 st dose For those 2-64 years of age who have immunocompromising conditions (and at least 5 or more years have elapsed from initial dose) CDC s Advisory Committee on Immunization Practices (ACIP) does not recommend multiple (more than 2) vaccinations at this time

6 Park City Primary Care Center Urban community health clinic where initial project began and follow up project continued Provides healthcare to citizens of Bridgeport and surrounding area

7 Park City s Patient Population Total patients seen last year: 6,781 Population comprised primarily of ethnic minorities Patients typically with high incidence of independent risk factors for pneumococcal disease Mostly diabetes, asthma, and HIV

8 Park City Population: Ethnicity Latino/Hisp anic Non Hispanic

9 Park City Population: Race American Indian or Alaskan Asian 39% Black/African American 59% Caucasian (Hispanic/Non Hispanic)

10 Park City Population: Gender 66% Female 34% Male

11 Park City Patient Population Total number of patients seen at the clinic last year was 6, confirmed cases of respiratory infections Clinic collected Bacterial pneumonia was the main infectious reason for hospitalization of patients, with 239 days spent at the hospital over the last 5 months

12 Compliance Reporting of Federally Qualified Health Centers Park City is a federally qualified health center must report standards for accreditation and continued funding (Annual UDS Report) Pneumococcal vaccine compliance rate will be a mandatory need to be tracked and recorded soon

13 Goals of the Initial Project which was Initiated May 2011 Evaluate the compliance rate of the Pneumovax coverage at the Park City clinic Compare it the national average Identify barriers to the vaccine s administration Help find solutions to these obstacles Implement improvement strategies Evaluate the paper to EHR transition Secures certification for Medicare payments and federal funding

14 Initial Project Cont. Identified guidelines-> CDC Found # of patients at PC that fit into the most represented risk categories 65 y.o and above** Asthma pts HIV pts Diabetes pts 2 64

15 Defining Compliance Consistent with CDC s guidelines of appropriate patients Vaccination documented in either paper or electronic charts Other factors considered When it was recorded that provider attempted to vaccinate but: Patient refused Patient eloped prior to vaccination Vaccine shortage (_ noted in patient s records)

16 Summary of Initial Project Compiled the data Analyzed the data Verified the conclusions Addressed need for improvement Identified some obstacles Asthma overlooked/confusing guidelines Complex diabetic cases Vaccine shortages Deficient patient knowledge base Cost Inefficient documentation

17 Percent Compliance Results of Initial Project EHR PPSV 23 Compliance Rates at Park City Center by Risk Factor Age 65 years and older: 42.9% Diabetes Mellitus (Type I and II): 36.8% Asthma: 57.1% HIV: 0% Age >65 DM (I and II) Asthma HIV 0 Age >65 DM (I and II) Asthma HIV

18 Follow up Project Goals: To determine whether compliance rates have improved since the initiation of the project To identify and address compliance barriers that still exist To initiate outreach projects within the community To continue to increase awareness amongst medical staff and patients

19 Percent Compliance Follow Up Data: EHR PPSV 23 Compliance Rates at Park City Center by Risk Factor Age 65 years and older: 51% Diabetes Mellitus (Type I and II): 50% Asthma: 33% HIV: 0% Age >65 DM (I and II) Asthma HIV 0 Age >65 DM (I and II) Asthma HIV

20 Additional Patient Population What about those CHFers? Added additional group for compliance measurements Found that: 50% compliance rate at Park City as reports in the EHR No national data found for this population group Will be useful information to have for follow up projects measuring improvement

21 Percent Compliance Percent Compliance Data Compared Initial Compliance Rates Follow Up Compliance Rates Age >65 40 Age > DM (I and II) Asthma HIV DM (I and II) Asthma HIV 0 Age >65 DM (I and II) Asthma HIV 0 Age >65 DM (I and II) Asthma HIV

22 Barriers to Improvement Identified Lack of vaccination of asthmatics Lack of provider knowledge Asthma being NEWER risk factor (New guidelines as of 2008) Focus of vaccination 65 and above driven

23 Barriers: Patient complexity Time Constraints (i.e. 15 minute appointments with patients that have a laundry list of problems and complaints)

24 Barriers: Vaccine shortage Cost for patients without insurance $56.31 with additional $28.00 administration fee Documentation i.e. discrepancies between paper charts and EHR

25 Barriers: Patient education Medical staff education and awareness

26 Addressing Barriers Asthmatics need this too? Distributed handouts to providers, medical assistants and nurses to reiterate which patients require this vaccine Reminders in computer (alerts providers that patient still needs to be vaccinated) Work in progress

27 Addressing Barriers Complexity of patients and time Constraints Unfortunately these are not modifiable barriers at this time this is where nursing staff and medical assistants play an integral role Distributed handouts outlining which patients require vaccination and encouraged medical assistant and nursing staff to remind providers when patients need this vaccine Standing order Worked into proposal for next updates to EHR/SAGE software Computer Alert system Proposed and currently in the process of being implemented pop up to remind providers that patients still require vaccine

28 Barriers Addressed Vaccine Shortage Medical supplies has ensured that there will be continued supply of this vaccine Two incidences recently: 10/6 and 9/7 Orders since then have restocked adequate supply of the vaccine Medical supplies was made aware of the importance of maintaining availability

29 Barriers Addressed Cost of Vaccine Awareness about patient payment assistance program offered by Merck Pharmaceuticals Providers can offer this info to patients that cannot pay Who Qualifies? (Must meet 3 Criteria): Reside in US and >19 years of age Have no health insurance coverage Have a household income of less than $43, 320 for individuals $58,280 for couples $88,200 for family of four

30

31 Barriers Addressed Discrepancies between paper charts and EHR Spoke to medical director of Park City about addressing this at next providers meeting Providers need to enter into EHR the date of vaccination if date of vaccination within the paper chart EHR fairly new (Jan 2011 start date) therefore, going to take time to decrease discrepancies Also multiple incidences where stated that patient received vaccine elsewhere in the SOAP note however, was not recorded in the vaccine history This will be addressed at the next provider meeting as well

32 Barriers Addressed Patient Education Pneumo what?? Patient information sheets hung in all exam rooms and left in waiting rooms Patient education sheets made available for providers to hand out courtesy Presented information about vaccine and distributed handouts to local senior centers and senior groups In the process of implementing reminder letters/phone calls to patients in need of vaccine

33

34 Barriers Addressed Medical Staff Education/Awareness Distributed information pamphlets courtesy of CDC to all medical assistants, nurses and providers Information sheets now hang in provider offices and in staff lounge Alert system in computer in the process of being implemented alerts providers of patient in need of vaccine Need to increased compliance and EHR/paper chart discrepancy issues to be addressed at next provider meeting

35

36 Proposal to the Physician Advisory Committee Provider Education Advantages: Ensures that all providers within the practice are informed of current guidelines for vaccination requirements. Ensures providers are updated in regards to new or changing guidelines. Studies: Two studies used provider education as the main intervention strategy, one in the area of adult general prevention 12 and one in prevention of injuries in children. 13 Both studies demonstrated improvements in provider counseling behaviors. 12,13 Implementation Steps: Distribute copy of guidelines to all practitioners as well as hanging guidelines throughout office Reiterate guidelines for seasonally specific vaccines and/or other vaccinations at provider meetings Notify providers when guidelines have been changed through alert system or distribution of paper copies of new guidelines

37 Bypass the physician/pa/aprn and utilize nursing/ma staff. Advantages: Team approach allows for better performance rates. Helps to prevent vaccinations from being overlooked/forgotten due to busy schedules and medical complexities of this patient population. Studies have proven that screening techniques are effective in the improvement of preventative care practices (see below). Studies: Two studies (both in adult cancer screening) bypassed the physician and had a nurse offer screening directly to patients, 15,16 and both studies demonstrated improvements in the provision of preventive services to patients. Overall, there is fair evidence supporting the use of bypassing the providers of racial/ethnic minority patients to offer standardized services directly to patients Implementation Steps: Training for nursing/ma staff regarding which patients require PPSV vaccine Allow for screening staff to obtain consent from the patient prior to provider entering room, therefore, jump starting the vaccination process Allow for reminder system i.e. health maintenance tab to be accessed by screening staff thus information is readily available and accessible for them to relay to providers

38 Tracking/reminder systems. Advantages: Effective, efficient and inexpensive once the computer system is already in place. Have been proven in multiple studies to improve rates of compliance (see below) Studies: Ten studies used tracking and/or reminder systems to improve quality of care; of these studies, two were in adult general prevention, 16,22 six in adult cancer screening, 3-7,22 one in tobacco cessation, 1 and one in endof-life care (completion of advance directives). 10 All ten studies demonstrated positive outcomes, primarily in the appropriateness of care (such as provision of preventive care, tobacco cessation counseling, or advance directive counseling) category. Overall, there is excellent evidence supporting the use of tracking/reminder systems aimed at providers of racial/ethnic minority patients In one practice, pneumococcal vaccination rates of high-risk persons increased from 29% before implementation to 86% following implementation of computerized chart reminders (Payne, 1995). 20 Implementation Steps: Design computer reminder system that

39 Standing Orders Advantage: Proven by many studies (see below) to be the most consistently effective way in which to improve vaccination compliance rate. Easy to use and simple to implement. Studies: One hospital study (Crouse, 1994) demonstrated that 40% of inpatients were vaccinated against influenza in hospitals using standing orders compared to 10% of patients in hospitals utilizing physician education only. 9 When standing orders for influenza and pneumococcal vaccination of persons 65 and older were implemented in an emergency room, 50% of patients eligible for influenza and 58% of persons eligible for pneumococcal vaccines were vaccinated (Rodriguez, 1993). In nursing homes, 90% of patients in homes with standing orders were vaccinated against influenza compared to 57% of patients in homes that required a consent form for vaccination (Patriarca, 1985). 21,19 Margolis (1988) found that use of standing orders in an outpatient clinic resulted in 81% of patients being offered influenza vaccine compared to 29% in a control group.another study (Klein, 1986) in an outpatient setting resulted in 78% of eligible patients being vaccinated against pneumococcal disease compared to 0% in a control group. 15,13 Implementation Steps: Outline criteria that need to be met indicating patient eligibility for vaccination Draft the actual standing order (examples attached for PPSV) Staff awareness and education regarding the use of the standing order Set up way in which to monitor vaccination rates to ensure that improvement is being made i.e. running reports

40 Mailed/Telephone Reminders Advantages: Direct phone calls ensure that patient receives and understands the message. Mailed reminders indicate that patient is still in need of vaccination, therefore, prompting them to make appointment. Dependent on literacy of population i.e. if a population is less literate than phone call reminders would be more beneficial Studies: McDowell (1986) found that telephoned reminders resulted in 37% of persons receiving influenza vaccine compared with 9.8% in a randomized control group. 17 Implementation Steps: Determine which patients are still in need of vaccinations with set criteria and generated reports Create list/spreadsheet of patients including names, addresses, phone numbers Eliminate patients who have transferred care or are since deceased Record patients who have been contacted and follow up to ensure they

41 Expanding Access in Health Care Settings Advantages: Helps to increase vaccination rates especially amongst disadvantaged and lower income populations i.e. populations with lack of transportation Implementation Steps: Determine access barriers amongst patient populations Set up drop in clinics or express lane vaccination services therefore, reducing distances patients must travel to receive vaccine and/or reducing time spent waiting to receive vaccine Outreach to increase community awareness of clinics or vaccination programs Possibly deliver vaccine in places previously not used i.e. pharmacy or senior centers/community centers in surrounding area

42 Patient Education Advantages: Educational materials are inexpensive and easy to distribute to patients in waiting room. Easy to implement and takes little staff time. Studies: When implemented as a pre-discharge measure in a hospital, pneumococcal and influenza vaccination rates were 75% and 78% respectively, compared to 0% of patients not given an informational handout (Bloom, 1988). This method has also been used to effectively increase tetanus toxoid administration (Cates, 1990). 8 Implementation Steps: Create or identify appropriate patient information sheet or use the Vaccine Information Statement (VIS) i.e. including check boxes that allow for patient to identify whether they fall into any of the high risk categories therefore, assessing their need for the vaccine See example of PPSV information sheet. Assign staff person to hand out specific educational information i.e. during influenza season hand out information about influenza and pneumococcal vaccine Assign and train staff person to be liason for patients i.e. to answer any initial questions they may have Train providers to request to see information sheets filled out by patients to determine whether they are in need of vaccination Measure effectiveness by generating reports to determine whether improvement in vaccination rates occur

43 Patient record coordination i.e. what is in the paper chart needs to be in the EHR as well Advantage: Patient information all in one place, therefore, saves provider time and energy having to go back and forth between chart and EHR. Information not as likely to be lost or overlooked. Improved efficacy in delivery of necessary services to patients i.e. vaccinations as it is easier to determine need. Implementation Steps: Train and remind providers and screening staff to record vaccination dates seen in paper chart in the EHR (in the vaccination history section not just the SOAP note) if it has not been done so previously Ask patients if they received vaccine and record information Take random sample of population to determine if discrepancy between chart and EHR information improves

44 Performance Feedback Advantages: Increases provider compliance rates by utilizing competition. Providers able to receive immediate feedback on how they are doing. Motivation for providers to improve on their compliance rates. Studies: In one study (Buffington, 1991), the percentage of eligible patients vaccinated against influenza at that practice office was 50%, compared to 34% in a control group that did not used the target- based approach. An additional 16% were vaccinated in public clinics, bringing the total percent of patients vaccinated to 66% among patients whose physicians used the target-based approach (6% higher than the Healthy People 2000 goal) compared with 50% among control physicians. One physician in this study vaccinated 79% of his patients. 2 Implementation Steps: Generate vaccination compliance by provider and distribute reports to each provider Recognize providers who have high compliance rates Meeting with providers to discuss ways in which to improve compliance rates across the board

45 For the Future: We must continue to increase awareness about the PPSV vaccine and vaccinate those in need Discrepancies between paper charts and EHR must be addressed and providers/medical staff must work together to consolidate patient information Continue outreach programs in the community Standing order for PPSV in the near future Alert systems need to be put in place to remind providers when vaccines are needed

46 Conclusion Park City showed improvement in most categories As awareness continues to increase, the compliance rates will follow Alert systems, i.e. pop ups in the EHR, are being implemented to help providers stay on track with compliance Providers and medical staff are working hard to increase compliance rates and have been receptive to all of our efforts Park City is well on its way to meeting and exceeding national averages and healthy people 2013 goals for compliance rates

47 References Agency for Healthcare Research and Quality. Strategies for Improving Minority Healthcare Quality. Centers for Disease Control and Prevention. Updated Recommendations for Prevention of Invasive Pneumococcal Disease Among Adults Using the 23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23). Available at: Accessed Oct Centers for Disease Control and Prevention. Prevention of pneumococcal disease: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 1997;46(RR-8):1 24. Centers for Disease Control and Prevention. Strategies for Increasing Adult Vaccination Rates. Immunization Action Coalition. Pneumococcus: Questions and Answers. Available at: Accessed October 20, Medical News Today. CDC Advisory Panel Votes To Update Pneumococcal Vaccination Recommendations. Available at: Accessed October 15, Merck Vaccine Patient Assistance Program. Merck Pharmaceuticals. Available at: Accessed October 24, Tuomanen, EI and Hibberd, PL. Pneumococcal Vaccine in Adults. In: UpToDate, Thorner, AR(Ed), UpToDate, Waltham, MA, World Health Oranization. 23-Valent Pneumococcal Polysaccharide Vaccine WHO Position Paper. Weekly Epidemiology Record. 2008; 42(83): Zimmerman RK, Nowalk MP, Tabbarah M, Hart JA, Fox DE, Raymund M. Understanding Adult vaccination in Urban, Lower-Socioeconomic Settings: Influence of Physician and Prevention Systems. FM Pitt-Net Primary Care Research Network Source: Ann Fam Med (6):534-41