Achieving the National Health Objective for Influenza Immunization: Success of an Institution-Wide Vaccination Program KRISTIN L.NICHOL,M.D.,M.P.H.,JANE E. KORN,M.D.,M.P.H.,KAREN L. MARGOLIS,M.D.,GREGORYA. POLAND,M.D., ROBERTA. PETZEL,M.D., RICHARD P. LoFGREN,M.D.,M.P.H.,M~~~~+~/~~,,w~~~~~~
I
nfluenza remains a major cause of morbidity, mortality, and lost productivity. Among the 10 leading causes of premature death in all age groups, influenza, with pneumonia, is also the fourth leading killer of the elderly [l]. As many as 20,000 to 40,000 deaths each year are attributed to influenza and its complications, with 80% to 90% of these occurring among those over age 64 [2]. The annual economic burden from influenza is estimated at 3 to 5 billion dollars [3]. Vaccination is effective in preventing influenza and results in health care cost savings for those at increased risk for complications [3-51. The Immunization Practices Advisory Committee of the Public Health Service [5], the American College of Physicians [6], and the Canadian Task Force on the Periodic Health Examination [7] recommend annual influenza vaccination for high-risk persons including the elderly, people with certain chronic diseases, and those who are institutionalized. A national vaccination rate of at least 60% for high-risk people is one of the 1990 health objectives for the nation [8]. Nationwide, however, only about 20% of all highrisk people received influenza vaccinations each year [9]. Similarly low vaccination rates have been documented in many primary care settings [W-24]. Interventions directed at care givers such as education, feedback, checklists, and nurse or computer-generated reminders may improve influenza vaccination rates, but generally only to 30% to 50% of targeted populations [11,12,16,20]. Organizational strategies such as mail cues or standing order policies, which do not rely on physician initiative, have been more successful, in some instances resulting in immunization rates of more than 50% for high-risk patients [15,18,23-271. Most of these previous efforts have been characterized by the use of only one type of intervention and the involvement of single clinics with relatively small numbers of patients. Past experience at the Department of Veterans Affairs Medical Center (VAMC) in Minneapolis has been similar. Following an educational program aimed at improving preventive health care delivery in the housestaff general medicine clinic, influenza vaccination rates for general medicine clinic patients over age 64 years increased from 9% in 1983 to 26% in 1984 [ 161. After the institution of a standing order policy for elderly patients followed in the same clinic, however, the vaccination rate of patients over age 64 increased to 69% in 1986 [27]. Although successful, this policy only affected older patients with general medicine clinic appointments coinciding with the immunization season. In 1987, an influenza immunization program was implemented at the Minneapolis VAMC to address
PURPOSE: To enhance influenza vaccination rates for high-risk outpatients at the Department of Veterans Affairs Medical Center (VAMC) in Minneapolis, Minnesota, an institution-wide immunization program was implemented during 1987. PATIENTS AND METHODS: The program COIIS~S~?~ of: (1) a hospital policy allowing nurses to vaccinate without a signed physician’s order, (2) stamped reminders on all clinic progress notes; (3) a %-week walk-in flu shot clinic; (4) influenza vaccination “stations” in the busiest clinic areas; and (5) a mailing to all outpatients. Risk characteristics and vaccination rates for patients were esthnated from a validated self-administered postcard questionnaire mailed to 500 randomly selected outpatients. For comparison, 500 patients were surveyed from each of three other Midwestern VAMCs without shnilar programs. RESULTS: Overall, 70.6% of Minneapolis patients were high-risk and 58.3% of them were vaccinated. In contrast, 69.9% of patients at the comparison medical centers were high-risk, but only 29.9% of them were vaccinated. CONCLUSION: The Minneapolis VAMC influenza vaccination program was highly successful and may serve as a useful model for achieving the national health objective for influenza immunization.
From the Department of Medicine and the Section of General Internal Medicine, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota. This study was presented in part at the 12th Annual Meeting of the Society of General Internal Medicine, Washington, D.C.. April 29.1989 (Clin Res 1989; 37: 799A). Requests for reprints should be addressed to Kristin L. Nichol. M.D., M.P.H., Section of General Internal Medicine (11 lo), Veterans Affairs Medical Center, Minneapolis, Minnesota 55417. Manuscript submitted November 3, 1989. and accepted rn revised form March 30. 1990. Current author addresses are: University of Massachusetts Medical Center (JEK), Worcester, Massachusetts: Hennepin County Medical Center, (KLM). Minneapolis, Minnesota: Mayo Clinic and Foundation (GAP), Rochester, Minnesota: and Veterans Affairs Medical Center (RPL). Pittsburgh, Pennsylvania.
156
August
1990
The American
Journal
of Medicine
Volume
89
INFLUENZA
the limitations of past efforts. The program represented a unique departure from other programs by combining a number of administrative, organizational, and patient-oriented educational and publicity interventions and applying them on an institution-wide scale. The program targeted all outpatients followed at the medical center, irrespective of their clinic affiliation or the date of their next appointment. The goal of the program was to achieve a vaccination rate of at least 60% for high-risk outpatients. In this study, we report on the overall effectiveness of this influenza vaccination program. MATERIAL AND METHODS Setting The Minneapolis VAMC is a University of Minnesota-affiliated teaching hospital that provides primary and tertiary care to nearly 31,000 outpatients, who make 278,000 visits each year. More than 7,500 of these patients are followed by 80 resident physicians in the general medicine clinic. Other patients receive care in medical subspecialty and non-internal medicine clinics. Previous influenza vaccination interventions for the general medicine clinic have been described elsewhere [16,27]. 1987 Program Description ADMINISTRATION AND ORGANIZATION: During the summer of 1987, the Minneapolis VAMC adopted a hospital policy allowing nurses to give influenza vaccinations to outpatients without a signed physician’s order. Any outpatient could receive the immunization as long as the patient had no.history of egg allergy or past hypersensitivity to influenza vaccine. A special stamp was placed by clinic clerks on all progress notes from November 1 through December 31,1987, to remind nurses to offer the vaccine to clinic patients during intake or exit interviews and to facilitate documentation of the injections. To accommodate patients without fall clinic appointments, a 2-week walk-in “flu shot” clinic was held in early November; advance appointments were not required. This clinic was staffed by one nurse from 8 AM to 3:30 PM weekdays, with a back-up nurse available as needed. After the conclusion of the walk-in clinic, from mid-November through December, two influenza vaccination “stations” were open for several hours daily in the lobbies of the two busiest clinic areas. These “stations” were established to facilitate vaccination of outpatients with appointments during the immunization season. Each was staffed with one nurse because regular clinic nurses did not necessarily see all clinic patients and sometimes lacked sufficient time during patient interviews to perform vaccinations. The immunization “station” nurses were encouraged to offer vaccine to all patients regardless of risk status in order to eliminate the need for detailed history taking and thereby minimize the time required for each injection. EDUCATION AND PUBLICITY: All 31,000 outpatients listed in the computer master file as having been seen at the Minneapolis VAMC from October 6, 1986, through October 6, 1987, received a letter providing information about influenza and people at highest risk for complications from infection. This letter stated that the patient’s physician strongly recommended a “flu shot” each year if the patient fell into a high-risk
VACCINATION
/ NICHOL
ET AL
group (age over 64 years or the presence of heart disease, lung disease, diabetes, or “other serious medical illness”) and included the dates, hours, and location of the walk-in “flu shot” clinic. Patients were also encouraged to request vaccination at the time of their regular clinic visits or at other facilities if they lived far from the medical center. On the back of the letter a “flu shot quiz” was printed addressing common concerns about influenza and the vaccine. Both the letter and quiz were modified from texts previously developed and tested at another VAMC [28]. A computergenerated cue was also added to all fall appointment letters that stated: “The flu season is coming. Don’t forget your flu shot.” Inservice educational sessions about influenza and the 1987 program were held for clinic nurses. All staff physicians received a memorandum describing the program. No other interventions for staff or resident physicians were conducted. Evaluation Total vaccine doses dispensed were monitored through pharmacy records. Clinic logs were used to track cumulative numbers of vaccinations administered in the walk-in clinic and influenza vaccination “stations.” OUTPATIENTRISKCHARACTERISTICSANDVACCINATION RATES: To estimate the risk characteristics and
vaccination rates for Minneapolis VAMC outpatients, 500 patients randomly selected from the outpatient roster used for the educational mailing were surveyed using a validated self-administered postcard questionnaire. Patients were asked whether they had received a “flu shot” during the fall of 1987, where they received their injection, if they had any medical illnesses that would place them into a high-risk category (lung disease, heart disease, diabetes, or “other serious medical illness”-the same categories that were included in the outpatient mailing), their age at their last birthday, and their name. A first mailing consisting of a covering letter and return postcard was sent in midFebruary 1988; a second was sent to non-responders 2 weeks later. CONCURRENT COMPARISON GROUPS: For comparison, three other VAMCs were selected. Each of these (sites A, B, and Cl was an urban, Midwestern, university-affiliated teaching hospital, with similar numbers of outpatient visits (& 5%) to the Minneapolis VAMC. Influenza vaccination activities at these hospitals were representative of those at many other centers. Immunizations were available in clinic areas when ordered by physicians for patients with autumn appointments; publicity was provided primarily through posters and other information displayed in waiting areas and examination rooms. In addition, at site A, a brief reminder was mailed to selected high-risk outpatients and an influenza vaccination clinic was held for patients with appointments several hours each day during the immunization season. From each of these comparison VAMCs, 500 patients were randomly selected from the computer file of all outpatients seen from October 6, 1986, to October 6, 1987, and were surveyed using the same questionnaire. The first mailing was sent in mid-March 1988 and a second was sent 2 weeks later. Statistical Analysis Categorical data were analyzed using standard techAugust
1990
The American
Journal
of Medicine
Volume
89
157
INFLUENZA
70
VACCINATION
/ NICHOL
m
MPLS
m
Other
ET AL
VAMC’s
60
IO
0 Age >64
Lung
Heart
Disease
Disease
Diabetes Mellitus
Other Diseases
niques for the comparison of multiple proportions [29]. Continuous variables were analyzed using oneway analysis of variance and t-tests for pairs of groups when appropriate [30]. All patients whose surveys were returned unopened and for whom there were no forwarding addresses were excluded from the analysis.
High Risk
Figure 1. Risk characteristics of survey respondents. Respondents indicating they had “other serious medical illness” comprise the “other diseases” category. High-risk = age older than 64 or presence of lung disease, heart disease, diabetes, or “other serious illness.” Results of comparison VAMCs have been pooled. *p = 0.004; +p = 0.02 (chi-square tests for comparison of multiple proportions, MPLS versus other VAMCs). MPLS = Minneapolis VAMC. Cl = confidence interval.
3, vaccination rates for elderly outpatients at the three comparison hospitals did not differ significantly from the corresponding 1987 statewide vaccination rates for elderly persons (all p >0.5), whereas for Minneapolis VAMC patients over age 64, the vaccination rate of 60.9% was 1.8 times that for the state of Minnesota [31] (p
I
nfluenza remains a major cause of morbidity, mortality, and lost productivity. Among the 10 leading causes of premature death in all age groups, influenza, with pneumonia, is also the fourth leading killer of the elderly [l]. As many as 20,000 to 40,000 deaths each year are attributed to influenza and its complications, with 80% to 90% of these occurring among those over age 64 [2]. The annual economic burden from influenza is estimated at 3 to 5 billion dollars [3]. Vaccination is effective in preventing influenza and results in health care cost savings for those at increased risk for complications [3-51. The Immunization Practices Advisory Committee of the Public Health Service [5], the American College of Physicians [6], and the Canadian Task Force on the Periodic Health Examination [7] recommend annual influenza vaccination for high-risk persons including the elderly, people with certain chronic diseases, and those who are institutionalized. A national vaccination rate of at least 60% for high-risk people is one of the 1990 health objectives for the nation [8]. Nationwide, however, only about 20% of all highrisk people received influenza vaccinations each year [9]. Similarly low vaccination rates have been documented in many primary care settings [W-24]. Interventions directed at care givers such as education, feedback, checklists, and nurse or computer-generated reminders may improve influenza vaccination rates, but generally only to 30% to 50% of targeted populations [11,12,16,20]. Organizational strategies such as mail cues or standing order policies, which do not rely on physician initiative, have been more successful, in some instances resulting in immunization rates of more than 50% for high-risk patients [15,18,23-271. Most of these previous efforts have been characterized by the use of only one type of intervention and the involvement of single clinics with relatively small numbers of patients. Past experience at the Department of Veterans Affairs Medical Center (VAMC) in Minneapolis has been similar. Following an educational program aimed at improving preventive health care delivery in the housestaff general medicine clinic, influenza vaccination rates for general medicine clinic patients over age 64 years increased from 9% in 1983 to 26% in 1984 [ 161. After the institution of a standing order policy for elderly patients followed in the same clinic, however, the vaccination rate of patients over age 64 increased to 69% in 1986 [27]. Although successful, this policy only affected older patients with general medicine clinic appointments coinciding with the immunization season. In 1987, an influenza immunization program was implemented at the Minneapolis VAMC to address
PURPOSE: To enhance influenza vaccination rates for high-risk outpatients at the Department of Veterans Affairs Medical Center (VAMC) in Minneapolis, Minnesota, an institution-wide immunization program was implemented during 1987. PATIENTS AND METHODS: The program COIIS~S~?~ of: (1) a hospital policy allowing nurses to vaccinate without a signed physician’s order, (2) stamped reminders on all clinic progress notes; (3) a %-week walk-in flu shot clinic; (4) influenza vaccination “stations” in the busiest clinic areas; and (5) a mailing to all outpatients. Risk characteristics and vaccination rates for patients were esthnated from a validated self-administered postcard questionnaire mailed to 500 randomly selected outpatients. For comparison, 500 patients were surveyed from each of three other Midwestern VAMCs without shnilar programs. RESULTS: Overall, 70.6% of Minneapolis patients were high-risk and 58.3% of them were vaccinated. In contrast, 69.9% of patients at the comparison medical centers were high-risk, but only 29.9% of them were vaccinated. CONCLUSION: The Minneapolis VAMC influenza vaccination program was highly successful and may serve as a useful model for achieving the national health objective for influenza immunization.
From the Department of Medicine and the Section of General Internal Medicine, Veterans Affairs Medical Center and University of Minnesota, Minneapolis, Minnesota. This study was presented in part at the 12th Annual Meeting of the Society of General Internal Medicine, Washington, D.C.. April 29.1989 (Clin Res 1989; 37: 799A). Requests for reprints should be addressed to Kristin L. Nichol. M.D., M.P.H., Section of General Internal Medicine (11 lo), Veterans Affairs Medical Center, Minneapolis, Minnesota 55417. Manuscript submitted November 3, 1989. and accepted rn revised form March 30. 1990. Current author addresses are: University of Massachusetts Medical Center (JEK), Worcester, Massachusetts: Hennepin County Medical Center, (KLM). Minneapolis, Minnesota: Mayo Clinic and Foundation (GAP), Rochester, Minnesota: and Veterans Affairs Medical Center (RPL). Pittsburgh, Pennsylvania.
156
August
1990
The American
Journal
of Medicine
Volume
89
INFLUENZA
the limitations of past efforts. The program represented a unique departure from other programs by combining a number of administrative, organizational, and patient-oriented educational and publicity interventions and applying them on an institution-wide scale. The program targeted all outpatients followed at the medical center, irrespective of their clinic affiliation or the date of their next appointment. The goal of the program was to achieve a vaccination rate of at least 60% for high-risk outpatients. In this study, we report on the overall effectiveness of this influenza vaccination program. MATERIAL AND METHODS Setting The Minneapolis VAMC is a University of Minnesota-affiliated teaching hospital that provides primary and tertiary care to nearly 31,000 outpatients, who make 278,000 visits each year. More than 7,500 of these patients are followed by 80 resident physicians in the general medicine clinic. Other patients receive care in medical subspecialty and non-internal medicine clinics. Previous influenza vaccination interventions for the general medicine clinic have been described elsewhere [16,27]. 1987 Program Description ADMINISTRATION AND ORGANIZATION: During the summer of 1987, the Minneapolis VAMC adopted a hospital policy allowing nurses to give influenza vaccinations to outpatients without a signed physician’s order. Any outpatient could receive the immunization as long as the patient had no.history of egg allergy or past hypersensitivity to influenza vaccine. A special stamp was placed by clinic clerks on all progress notes from November 1 through December 31,1987, to remind nurses to offer the vaccine to clinic patients during intake or exit interviews and to facilitate documentation of the injections. To accommodate patients without fall clinic appointments, a 2-week walk-in “flu shot” clinic was held in early November; advance appointments were not required. This clinic was staffed by one nurse from 8 AM to 3:30 PM weekdays, with a back-up nurse available as needed. After the conclusion of the walk-in clinic, from mid-November through December, two influenza vaccination “stations” were open for several hours daily in the lobbies of the two busiest clinic areas. These “stations” were established to facilitate vaccination of outpatients with appointments during the immunization season. Each was staffed with one nurse because regular clinic nurses did not necessarily see all clinic patients and sometimes lacked sufficient time during patient interviews to perform vaccinations. The immunization “station” nurses were encouraged to offer vaccine to all patients regardless of risk status in order to eliminate the need for detailed history taking and thereby minimize the time required for each injection. EDUCATION AND PUBLICITY: All 31,000 outpatients listed in the computer master file as having been seen at the Minneapolis VAMC from October 6, 1986, through October 6, 1987, received a letter providing information about influenza and people at highest risk for complications from infection. This letter stated that the patient’s physician strongly recommended a “flu shot” each year if the patient fell into a high-risk
VACCINATION
/ NICHOL
ET AL
group (age over 64 years or the presence of heart disease, lung disease, diabetes, or “other serious medical illness”) and included the dates, hours, and location of the walk-in “flu shot” clinic. Patients were also encouraged to request vaccination at the time of their regular clinic visits or at other facilities if they lived far from the medical center. On the back of the letter a “flu shot quiz” was printed addressing common concerns about influenza and the vaccine. Both the letter and quiz were modified from texts previously developed and tested at another VAMC [28]. A computergenerated cue was also added to all fall appointment letters that stated: “The flu season is coming. Don’t forget your flu shot.” Inservice educational sessions about influenza and the 1987 program were held for clinic nurses. All staff physicians received a memorandum describing the program. No other interventions for staff or resident physicians were conducted. Evaluation Total vaccine doses dispensed were monitored through pharmacy records. Clinic logs were used to track cumulative numbers of vaccinations administered in the walk-in clinic and influenza vaccination “stations.” OUTPATIENTRISKCHARACTERISTICSANDVACCINATION RATES: To estimate the risk characteristics and
vaccination rates for Minneapolis VAMC outpatients, 500 patients randomly selected from the outpatient roster used for the educational mailing were surveyed using a validated self-administered postcard questionnaire. Patients were asked whether they had received a “flu shot” during the fall of 1987, where they received their injection, if they had any medical illnesses that would place them into a high-risk category (lung disease, heart disease, diabetes, or “other serious medical illness”-the same categories that were included in the outpatient mailing), their age at their last birthday, and their name. A first mailing consisting of a covering letter and return postcard was sent in midFebruary 1988; a second was sent to non-responders 2 weeks later. CONCURRENT COMPARISON GROUPS: For comparison, three other VAMCs were selected. Each of these (sites A, B, and Cl was an urban, Midwestern, university-affiliated teaching hospital, with similar numbers of outpatient visits (& 5%) to the Minneapolis VAMC. Influenza vaccination activities at these hospitals were representative of those at many other centers. Immunizations were available in clinic areas when ordered by physicians for patients with autumn appointments; publicity was provided primarily through posters and other information displayed in waiting areas and examination rooms. In addition, at site A, a brief reminder was mailed to selected high-risk outpatients and an influenza vaccination clinic was held for patients with appointments several hours each day during the immunization season. From each of these comparison VAMCs, 500 patients were randomly selected from the computer file of all outpatients seen from October 6, 1986, to October 6, 1987, and were surveyed using the same questionnaire. The first mailing was sent in mid-March 1988 and a second was sent 2 weeks later. Statistical Analysis Categorical data were analyzed using standard techAugust
1990
The American
Journal
of Medicine
Volume
89
157
INFLUENZA
70
VACCINATION
/ NICHOL
m
MPLS
m
Other
ET AL
VAMC’s
60
IO
0 Age >64
Lung
Heart
Disease
Disease
Diabetes Mellitus
Other Diseases
niques for the comparison of multiple proportions [29]. Continuous variables were analyzed using oneway analysis of variance and t-tests for pairs of groups when appropriate [30]. All patients whose surveys were returned unopened and for whom there were no forwarding addresses were excluded from the analysis.
High Risk
Figure 1. Risk characteristics of survey respondents. Respondents indicating they had “other serious medical illness” comprise the “other diseases” category. High-risk = age older than 64 or presence of lung disease, heart disease, diabetes, or “other serious illness.” Results of comparison VAMCs have been pooled. *p = 0.004; +p = 0.02 (chi-square tests for comparison of multiple proportions, MPLS versus other VAMCs). MPLS = Minneapolis VAMC. Cl = confidence interval.
3, vaccination rates for elderly outpatients at the three comparison hospitals did not differ significantly from the corresponding 1987 statewide vaccination rates for elderly persons (all p >0.5), whereas for Minneapolis VAMC patients over age 64, the vaccination rate of 60.9% was 1.8 times that for the state of Minnesota [31] (p
