Clinical Studies| Volume 105, ISSUE 5, P385-392, November 1998

Ten-year durability and success of an organized program to increase influenza and pneumococcal vaccination rates among high-risk adults

  • Kristin L Nichol
    Requests for reprints should be addressed to Kristin L Nichol, MD, MPH, Medicine Service (111), VA Medical Center, One Veterans Drive, Minneapolis, Minnesota 55417
    Medicine Service, VA Medical Center, and Department of Medicine, University of Minnesota, Minneapolis, Minnesota., USA
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      Purpose: Influenza and pneumococcal vaccines are underused. Systems approaches that incorporate administrative and organizational strategies are more successful than education of providers for improving vaccination rates. Little has been published on the long-term success and durability of such efforts.
      Methods: We performed a 10-year time-series study to examine the durability and success of an ongoing, multifaceted, institution-wide influenza and pneumococcal vaccination program. The program was first implemented at the Minneapolis Department of Veterans Affairs (VA) Medical Center in 1987–88 following the demonstration that a clinic-based standing order policy was much more successful than provider education for improving vaccine delivery. The program ensures that vaccine is offered to all high-risk patients followed up at the medical center, promotes convenient access for patients, and facilitates efficient administration of vaccine. Specific elements include an annual mailing to patients, standing orders for nurses, walk-in clinics, and the use of standardized, preprinted documentation forms. Initially the program targeted high-risk outpatients for influenza vaccination. It was extended to include inpatients in 1989–90. Pneumococcal vaccinations were added to the program in 1994–95. Vaccination rates are estimated each year from surveys mailed to randomly selected patients, and vaccine utilization is monitored through pharmacy logs.
      Results: The survey response rates have exceeded 75% each year. Influenza vaccination rates for all high-risk patients followed up at the medical center have increased from 58% following the 1987–88 vaccination season to 84% in 1996–97 (P < 0.001). Pneumococcal vaccination rates have also increased from 34% in 1994–95 to 63% in 1996–97 (P < 0.001). Vaccination rates are similar for inpatients and outpatients, but rates for high-risk patients < 65 years of age remain lower than for the elderly: 69% versus 89% for influenza, 1996–97 (P < 0.001); 52% versus 66% for pneumococcal, 1996–97 (P = 0.05). For elderly patients followed up at the medical center, influenza (89% versus 67%, P < 0.0001) and pneumococcal (66% versus 43%, P < 0.0001) vaccination rates significantly exceeded those for the state of Minnesota in 1996–97. The annual number of influenza vaccine doses dispensed has increased from 10,000 in 1987–88 to more than 22,000 in 1996–97; and more than 13,000 doses of pneumococcal vaccine have been administered from 1994–95 through 1996–97.
      Conclusion: This simple, multifaceted program that incorporates administrative and organizational strategies to enhance influenza and pneumococcal vaccination rates has been highly durable and successful over a 10-year peroid. Similar strategies if implemented in other settings may enhance vaccination rates for the millions of high-risk patients who have yet to be immunized.
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        • Fedson D.S
        • for the National Vaccine Advisory Committee
        Adult immunization. Summary of the National Vaccine Advisory Committee Report.
        JAMA. 1994; 272: 1133-1137
        • Williams W.W
        • Hickson M.A
        • Kane M.A
        • et al.
        Immunization policies and vaccine coverage among adults.
        Ann Intern Med. 1988; 108: 606-625
        • Centers for Disease Control and Prevention
        Prevention and control of influenza. Recommendations of the Advisory Committee on Immunization Practices.
        MMWR. 1997; 46
        • Centers for Disease Control and Prevention
        Prevention of pneumococcal disease. Recommendations of the Advisory Committee on Immunization Practices.
        MMWR. 1997; 46
        • Centers for Disease Control and Prevention
        Pneumococcal and influenza vaccination levels among adults aged ≥65 years—United States, 1995.
        MMWR. 1997; 46: 913-919
        • Fedson D.S
        Influenza and pneumococcal immunization strategies for physicians.
        Chest. 1987; 91: 436-443
      1. Fedson DS. Influenza prevention and control. Past practices and future prospects. Am J Med 1987;82(suppl 6A):42–47.

        • McKinney W.P
        • Barnas G.P
        Influenza immunization of the elderly.
        Am J Public Health. 1989; 79: 1422-1424
        • Fiebach N
        • Beckett W
        Prevention of respiratory infections in adults. Influenza and pneumococcal vaccines.
        Arch Intern Med. 1994; 154: 2545-2557
        • Fedson D.S
        Clinical practice and public policy for influenza and pneumococcal vaccination of the elderly.
        Clin Geriatr Med. 1992; 8: 183-199
        • Korn J.E
        • Schlossberg L.A
        • Rich E.D
        Improved preventive care following an intervention during an ambulatory care rotation.
        J Gen Intern Med. 1988; 3: 156-160
        • Margolis K.L
        • Lofgren R.P
        • Korn J.E
        Organizational strategies to improve influenza vaccine delivery.
        Arch Intern Med. 1988; 148: 2205-2207
        • Nichol K.L
        • Korn J.E
        • Margolis K.L
        • et al.
        Achieving the national health objective for influenza immunization.
        Am J Med. 1990; 89: 156-160
        • Nichol K.L
        Improving influenza vaccination rates for high-risk inpatients.
        Am J Med. 1991; 91: 584-588
        • Nichol K.L
        Long-term success with the national health objective for influenza vaccination.
        J Gen Intern Med. 1992; 7: 595-600
      2. Lofgren RP, Paul JM, Kefalos SG, Nichol KL. A multifaceted influenza vaccination program can be exported successfully to a different clinical site. Clin Res 1990;38:864A. Abstract.

        • Margolis K.L
        • Nichol K.L
        • Wuorenma J
        • Von Sternberg T.L
        Exporting a successful influenza vaccination program from a teaching hospital to a community outpatient setting.
        J Am Geriatr Soc. 1992; 40: 1021-1023
        • Public Health Service
        Healthy People 2000 National Health Promotion and Disease Prevention Objectives. US Department of Health and Human Services, Public Health Service, DHHS publication PHS 91-50213, Washington, DC1991: 122-123
        • Nichol K.L
        • Korn J.E
        • Baum P
        Estimation of outpatient risk characteristics and influenza vaccination status.
        Am J Prev Med. 1991; 7: 199-203
      3. Centers for Disease Control and Prevention. Influenza vaccination levels in selected states—behavioral risk factor surveillance system. 1987. MMWR 1989;36:124–133.

        • Centers for Disease Control and Prevention
        Pneumococcal and influenza vaccination levels among adults aged ≥65 years—United States, 1993.
        MMWR. 1996; 45: 853-859
      4. Centers for Disease Control and Prevention. State- and sex-specific prevalence of selected characteristics—behavioral risk factor surveillance system, 1994 and 1995. Table 18. Percentage of adults ≥65 years of age who reported ever having a pneumococcal vaccination or having an influenza vaccination in the past 1 year–Behavioral Risk Factor Surveillance System, 1995. MMWR 1997;46(no SS-3):25.

        • Centers for Disease Control and Prevention
        1996 BRFSS summary prevalence report. Centers for Disease Control and Prevention, Atlanta, Ga1998: 106-108
        • Thompson R.S
        Systems approaches and the delivery of health services.
        JAMA. 1997; 277: 670-671
        • Cohen D.I
        • Littenberg B
        • Wetzel C
        • Neuhauser D
        Improving physician compliance with preventive medicine guidelines.
        Med Care. 1982; 20: 1040-1045
        • Crouse B.J
        • Nichol K
        • Peterson D.C
        • Grimm M.B
        Hospital-based strategies for improving influenza vaccination rates.
        J Fam Pract. 1994; 38: 258-261
        • Lomas J
        • Anderson G.M
        Domnick-Pierre K, et al. Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians.
        NEJM. 1989; 321: 1306-1311
        • Kosecoff J
        • Kanouse D.E
        • Rogers W.H
        • et al.
        Effects of the National Institutes of Health consensus development program on physician practice.
        JAMA. 1987; 258: 2708-2713
        • Lee T.H
        • Pearson S.D
        • Johnson P.A
        • et al.
        Failure of information as an intervention to modify clinical management.
        Ann Intern Med. 1995; 122: 434-437
        • Thompson R.S
        • Taplin S.H
        • McAfee T.A
        • et al.
        Primary and secondary prevention services in clinical practice.
        JAMA. 1995; 273: 1130-1135
        • Schoenbaum S.C
        Implementation of preventive services in an HMO practice.
        J Gen Intern Med. 1990; 5: s123-s127
        • Schoenbaum S.C
        Developing effective systems for delivery of vaccines.
        Infect Dis Clin NA. 1990; 4: 199-209
        • Barton M.B
        • Schoenbaum S.C
        Improving influenza vaccination performance in an HMO setting.
        Am J Public Health. 1990; 80: 534-536
        • Buffington J
        • Bell K.M
        • LaForce F.M
        A target-based model for increasing influenza immunizations in private practice.
        J Gen Intern Med. 1991; 6: 204-209
      5. Centers for Disease Control and Prevention. Adult immunization: knowledge, attitudes, and practices—DeKalb and Fulton Counties, Georgia. 1988. MMWR 1988;37:657–661.

        • Nichol K.L
        • Lofgren R.P
        • Gapinski J
        Influenza vaccination. Knowl-edge, attitudes and behavior among high-risk outpatients.
        Arch Intern Med. 1992; 152: 106-110
        • Nichol K.L
        • MacDonald R
        • Hauge M
        Factors associated with influenza and pneumococcal vaccination behavior among high-risk adults.
        J Gen Intern Med. 1996; 11: 673-677
        • Williams W.W
        Hawaii pneumococcal disease initiative.
        in: Proceeding of the 26th National Immunization Conference. Centers for Disease Control and Prevention, Atlanta, Ga1992: 117-122
        • Buffington J
        • LaForce F.M
        Achievable influenza immunization rates in the elderly.
        NY State J Med. 1991; 91: 433-435
        • Kottke T.E
        • Solberg L.I
        • Brekke M.L
        • et al.
        Delivery rates for preventive services in 44 midwestern clinics.
        Mayo Clin Proc. 1997; 72: 515-523
        • Centers for Disease Control and Prevention
        Assessing adult vaccination status at age 50 years.
        MMWR. 1995; 44: 561-563
        • Nichol K.L
        • Grimm M.B
        • Peterson D.C
        Immunizations in long-term care facilities.
        J Am Geriatr Soc. 1996; 44: 349-355
        • Centers for Disease Control and Prevention
        Influenza and pneumococcal vaccination coverage levels among persons aged ≥65 years—United States, 1973–1993.
        MMWR. 1995; 44: 506-515
        • Honkanen P.O
        • Keistinen T
        • Kivela S.L
        The impact of vaccination strategy and methods of information on influenza and pneumococcal vaccination coverage in the elderly population.
        Vaccine. 1997; 15: 317-320
      6. MacDonald R, Baken L, Nelson A, Nichol KL. Validation of self-report of influenza and pneumococcal vaccination status in elderly outpatients. Am J Med. In press.