Improving Flu Vaccination Rates at the Institute for Family Health at 17th Street the Old-Fashioned Way Anup Bhandiwad, MD Andrew Chen, MD Rebecca Giusti, MD Ines Teuma, MD
Background Since 2010 there have been between 9.2 and 35.6 million cases of flu in the US, between 140,000 and 710,000 hospitalizations, and between 12,000 and 56,000 influenza related deaths annually CDC guidelines indicate that flu vaccine compliance should be between 80-90% Flu vaccine rates in 2016-2017 in New York state was only 50% Common barriers include lack of provider s time to counsel patients about the benefits of the flu vaccine, failure of providers to offer the vaccine, lack of patient awareness of the importance of the vaccine, and misconceptions surrounding the dangers of obtaining the flu vaccine Several studies showed outreach, via a mailed letter, could improve vaccination rates
Objective The purpose of this project and the only objective measurement of success is to increase the number of patients in the panel of participating resident physicians who have received the flu shot, with a goal of 90% Setting: Institute for Family Health at 17th Street (an urban Federally Qualified Health Center in NYC) Intervention Group: all patients (age 6 mo and older) in the respective panels of the four participating physicians who did not have a flu vaccine documented for the 2017-2018 flu season, as identified by Gaps List data, a list of non-adherent patients derived from electronic medical records (EMR) documentation, and confirmed by review of our EMR
Methods & Data Collection Resident physicians mailed a handout, in English or Spanish, in January 2018 to patients who did not have a documented influenza vaccine identified by Gaps List data, Handout included: 1. Letter from providers regarding how to get/document a vaccination (on right) 2. CDC Information Sheet, No More Excuses: You Need a Flu Vaccine Data from December 2017 to February 2018 was collected via the Institute for Family Health Quality Metrics and Gaps Lists data for the 4 resident physicians Data from December 2016 to February 2017 for the same providers was used as a comparison group
Methods & Data Collection Below: CDC Information Sheet - No More Excuses: You Need a Flu Vaccine - sent in handout https://www.cdc.gov/flu/pdf/freeresources/general/ no-excuses-flu-vaccine-print.pdf
Results Comparison Group (2016-2017) Influenza Gaps List - Dec 2016 Number immunized by Feb 2017 % Immunized by Feb 2017 Andrew Chen 15 0 0 Anup Bhandiwad 24 0 0 Ines Teuma 23 2 8.70% Rebecca Giusti 13 0 0 Total 75 2 2.67% Intervention Group (2017-2018) Influenza Gaps List - Dec 2017 Number immunized by Feb 2018 % Immunized by Feb 2018 Andrew Chen 35 1 2.86% Anup Bhandiwad 29 0 0.00% Ines Teuma 33 1 3.03% Rebecca Giusti 26 1 3.85% Total 123 3 2.44%
Results Change in percentages affected by change in total number of patients in provider panel Patients identified at December Gaps Lists and in 2017-2018 for patients intervened upon and their vaccination rates in February
Discussion This continuous quality improvement study aimed to improve influenza vaccination adherence with direct patient communication in the form of a mailed letter and informational flyer to patients of the four resident physicians. Researchers compared the change in immunization rates following the intervention, from December to February, via the Institute for Family Health Quality Metrics and Gaps Lists. A comparison group was influenza vaccination rates over the same period of time from the year prior.
Discussion Only 2.4% (3 out of 123) patients who received the mailing came into the clinic to get their flu shot by February 2018. Last year over the same time frame, 2.7% (2 out of 75) patients got their flu shot. Findings showed no statistically significant difference between the comparison group and the intervention. Any change noted likely represented a secular trend, meaning a certain number of patient would have received the flu vaccine over a period of time, regardless of whether an intervention was performed given a similar change in the comparison group. Of note, the rate of vaccinations was in fact lower this year as the total number of patients in the intervention increased likely secondary to several barriers.
Strengths Intervention performed in middle of influenza season eliminating the need for outreach in patients who routinely get influenza vaccine reducing Provider & Staff time and resources needed Handouts included a CDC Information Sheet - increasing legitimacy and assuring up to date information Also allows study to be easily replicated in future years without the need of the providers or staff to update information handout with new information A signed Institute for Family Health letter provided a personalized note specifically directed towards the identified patient In addition to information regarding how to get the vaccine, information was given on how to confirm a vaccination obtained at an outside facility for documentation purposes
Clinic and Documentation Barriers Providers inability to correctly document influenza vaccinations obtained at an outside facility Often Best Practice Advisory (BPAs) in EPIC are Postponed rather than obtaining documentation and resolving the BPA Postponed items are still identified in the Gaps List Recent clinic move (in December 2017) might have posed a distance barrier Lack of influenza vaccine for significant portion of January and early February Long clinic wait times Unconfirmed mailing addresses
Intervention Design Barriers Timing of intervention created a limited timeframe to obtain data Study started several months into the flu season Small patient population (123 patients) Language Barrier - letters were sent in only Spanish and English Study used Gaps List data - this likely underestimated number of patients vaccinated given the need for documentation Intervention might have gotten participants to go to local health care centers or pharmacies to get vaccinated Given letters mailed out, outreach did not allow for providers to answer participant specific questions or coordinate the visit
Population Barriers Negative media attention for 2017-2018 flu season: ineffective flu vaccine Patients identified in mid-late of the flu season are likely among the more challenging patients to get vaccinations Are hesitant to vaccinations in general Feel that they are healthy enough to combat the flu Have thoughts that the vaccination does not work Have misconceptions about the influenza vaccine, identify urban myths (eg. can make you sick) Financial barriers Lack of insurance, co-pay fees, lack of income due to lost work hours, cost of the vaccine itself
Conclusions Despite statistically insignificant changes with the intervention compared to the comparison group, this quality improvement project was a good exercise in identifying limitations to the study and in learning how to implement effective healthy change in a patient population. In this intervention, one letter was an ineffective intervention in convincing patients to get the influenza vaccine. However, given the discussed barriers, especially unique barriers such as the move of the clinic, a repeated study next year would be needed to validate this conclusion. This study laid a solid framework for creating a more effective study during the 2018-2019 flu season.
Suggestions for Further Research A handout or short presentation could be given to providers to review proper documentation of vaccinations Addresses should be confirmed and letters could be mailed earlier in the flu season Flu vaccine availability should be confirmed at the time the letters mailed Provide letters in French, Chinese, Arabic, or other primary languages of the patient population Provider or Clinic Staff could call patients to confirm receipt of the flu shot mailing and to answer any specific questions Health center sets up free vaccine stand weekly to expedite vaccinations and decrease wait times
Bibliography 1. Disease Burden of Influenza accessed from www.cdc.gov/flu/about/disease/burden.htm. January 10, 2018. 2. 2016-17 Influenza Season Vaccination Coverage Report. Accessed from www.cdc.gov/flu/fluvaxview/reportshtml/reporti1617/reporti/index.html. January 10, 2018. 3. Bay, S. Crawford, D. Using Technology to Affect Influenza Vaccine Coverage Among Children with Chronic Respiratory Conditions Journal of Pediatric Healthcare. 2017: 31(2): 155-160. 4. Vaccine-Preventable Diseases: Improving Vaccination Coverage in Children, Adolescents, and Adults. June 18, 1999. Accessed from www.cdc.gov/mmwr/preview/mmwrhtml/rr4808a1.htm. January 10, 2018. 5. Larson E, Bergman J, Heidrich F, et. al. Do Postcard Reminders Improve Influenza Compliance? A Prospective Trial of Different Postcard Cues. Medical Care. 1982 June; 20 (6):639-48.