Current issues of ACP Journal Club are published in Annals of Internal Medicine


Quality Improvement

Patient and provider education plus redefining medical staff tasks improved compliance with vaccination

ACP J Club. 1995 May-June;122:83. doi:10.7326/ACPJC-1995-122-3-083


Source Citation

Herman CJ, Speroff T, Cebul RD. Improving compliance with immunization in the older adult: results of a randomized cohort study. J Am Geriatr Soc. 1994 Nov;42:1154-9.


Abstract

Objective

To evaluate the effectiveness of 3 approaches for improving compliance with influenza and pneumococcal vaccination among elderly patients.

Design

Randomized controlled trial with 9-month follow-up.

Setting

3 ambulatory medical clinics of a public urban teaching hospital.

Patients

901 patients evaluated for pneumococcal vaccination compliance and 756 patients evaluated for influenza vaccination compliance who were ≥ 65 years of age and were seen by medical personnel for either a medication refill or education. Exclusion criteria were contraindication to vaccination, previous pneumococcal vaccination (for the evaluation of pneumococcal vaccination compliance), or nonappearance for 2 consecutive influenza seasons (for the evaluation of influenza vaccination compliance).

Intervention

The 3 clinics were randomly assigned to 1 of the 3 arms of the study. New patients were randomly assigned to 1 of the 3 medical clinics. All clinic staff received education in vaccination standards. The control group received no further intervention (n = 295 patients for the evaluation of pneumococcal vaccination compliance; n = 271 patients for the evaluation of influenza vaccination; 23 resident physicians, 1 nurse, 1 nurse practitioner). In the patient education group, educational materials were given to the patients (n = 292 patients for pneumococcal vaccination; n = 242 patients for influenza vaccination; 22 resident physicians, 1 nurse, 1 nurse practitioner). In the prevention team group, patient education was offered and staff had their tasks redefined to facilitate compliance (n = 314 patients for pneumococcal vaccination; n = 243 patients for influenza vaccination; 21 resident physicians, 1 nurse, 1 nurse practitioner).

Main outcome measures

Offering and receipt of vaccinations.

Main results

During the 6-month intervention period, pneumococcal vaccination was offered to more patients in the prevention team group (28.3%) than to patients in either the patient education (6.5%, {95% CI for the 21.8% absolute difference 16.1% to 25.6%}*, P < 0.001) or control (5.4%, {CI for the 22.9% absolute difference 17.3% to 28.5%}*, P < 0.001) groups. This difference remained after adjusting for age, sex, race, and physicians' attitudes and level of training. The rates of actual receipt of the vaccine were similar to the rates of offering. During the intervention, influenza vaccination was offered more frequently to patients in the prevention team group (68.3%) than to patients in either the patient education (50.4%, {CI for the 17.9% absolute difference 9.3% to 26.5%}*, P < 0.001) or the control (47.6%, {CI for the 20.7% absolute difference 12.4% to 29.1%}*, P < 0.001) groups, even after adjusting for baseline confounders.

Conclusion

Patient and provider education plus the redefinition of medical staff tasks improved compliance with influenza and pneumococcal vaccination among elderly patients.

Source of funding: Case Western Reserve University Teaching Nursing Home Program.

For article reprint: Dr. C.J. Herman, Division of Gerontology, Department of Medicine, 2211 Lomas Northeast, Albuquerque, NM 87131, USA. FAX 505-272-4628.

*Numbers calculated from data in article.


Commentary

Overwhelming evidence shows that influenza and pneumococcal immunization reduces morbidity and mortality in high-risk persons. A critically important challenge is how to increase the vaccination of these high-risk persons. The U.S. Public Health Service has set a goal of vaccinating 60% of high-risk residents in the community and 80% of residents in institutions. How can we use practice-based strategies to maximize vaccination rates?

The study by Herman and colleagues examines incremental strategies to increase the rate of influenza and pneumococcal vaccinations for patients with appointments at 3 resident-faculty physician practice "firms" of an urban, academic medical center. Although the setting and the population may not reflect other practices, the study confirms an important finding: The combination of empowering practice staff members to give vaccines, changing the clinic approach to vaccination delivery, and offering patient and provider education may dramatically increase the vaccination rate of the clinic.

Two additional points are confirmed by the study. First, patients who have accepted vaccinations in the past generally continue to accept vaccinations. Therefore, education efforts may need to be directed toward persons who have refused or never received vaccinations. Second, physicians overestimate their rate of compliance with preventive interventions, such as vaccination. Measurement of these rates may be an important prerequisite to improving preventive care. The evolving practice-based information systems, featuring patient and clinician "reminders," will also provide practitioners with the means to evaluate the effectiveness of their preventive care programs.

William P. Moran, MD, MS
Bowman Gray School of MedicineWinston-Salem, North Carolina, USA