Improving Adult Immunizations in the Primary Care Setting
Improving Adult Immunizations in the Primary Care Setting
Orienting a practice to promote adult vaccination showed improved adult vaccination rates in this and other studies. This required a culture shift and an investment of time for the practice, one that is becoming increasingly difficult given the current time constraints in primary care practice. All practices reported spending between 12 and 72 hours on this program over the course of approximately 12 months. Analyses revealed no significant difference at the practice level between immunization rates and the number of hours the practice spent on the program. Additionally, when the effect of EMR status on vaccine delivery was evaluated, there was no association with EMR status and improved vaccination rates. These data might help persuade smaller practices that do not have as many resources to try quality improvement, as this program showed it could be effective in paper-based practices and with minimal time allotted.
An integral part of the practice's success was the development of the practice team. The value of the practice team meeting on a continual basis to review their quality improvement progress was vital to the success of any quality improvement work, and was demonstrated in other studies. Practice redesign in this program required a shifting of responsibilities among individuals in a practice in an effort to streamline activities and responsibilities and better orient the practice toward the patient's health. The team was taught in the coaching calls to share responsibilities to accomplish a common goal. Quality improvement faculty stressed the value of a practice champion who oversaw the quality improvement work and worked to motivate the group. All physicians in this study valued this role, and reported integrating advice from the practice team into their practice improvement work. Similar to other practice teams reported in the literature, this program required the individuals to surrender a small percentage of their autonomy to better serve the goals of the practice as a whole. For instance in 1 practice, the physician gave up the task of screening, passing this responsibility on to the nurse, allowing the physician more time to counsel the patient on the benefits of immunization. As the burden of chronic disease is increasing in our population, physicians are managing more and more complex patients, needing more time in the clinical encounter. These complex patients are often recommended various immunizations because of the susceptibility their disease invokes on the immune system. Few guidelines exist that offer recommendations on treating multiple chronic conditions. In light of these increasing challenges, the team approach is becoming a valuable mode of delivering comprehensive care to these complex patients by re-prioritizing responsibilities among the practice team.
It is difficult to anticipate vaccine demand, making it harder to decide what amounts to purchase. This creates a financial risk for the practice upfront without being able to appropriately anticipate what the demand will be. A recent study evaluated physicians' rationale behind the purchase of vaccinations and revealed that for herpes zoster, Tdap, and hepatitis B, many did not stock these vaccines because of their high inventory cost, associated low reimbursement, and inconsistent insurance coverage. Because only approximately 20% of internal medicine physicians carry all recommended adult vaccinations, it is not surprising that adult vaccination rates are subpar. Interestingly, in this study, the rates of Td/Tdap increased significantly across various measures from before to after intervention. Additionally, physicians administered herpes zoster, Tdap, and hepatitis B at more annual visits after intervention, suggesting either they made better use of their vaccine supply or increased their vaccine supply. Further data would be needed to understand this increase. Still, only a third of physicians in this study kept a supply of hepatitis B, and even fewer maintained supplies of hepatitis A, herpes zoster, human papilloma virus, and meningococcal vaccinations. Adequate supply of adult vaccinations is important to the health of the population. Therefore, it is not only imperative that physicians be reminded to recommend vaccinations, but to stock them as well.
Immunizations were fundamental to the success of health promotion of the population. However, our current system is oriented toward managing disease, with few resources targeted toward prevention. Other studies, like this one, found that a physician self-reported barrier to adult immunizations was insurance coverage. This might create a bias to refrain from suggesting immunizations to patients whom the physician suspected did not have insurance coverage for them. Another potential reason for low immunization rates among adults might be that most physicians provided immunizations at well visits, which occur annually at best. Results from this study showed that the majority of vaccinations occurred at annual well visits; a smaller percentage occurred at follow-up visits, and very few occurred at acute visits. Immunizations should be recommended at well and sick visits, requiring a restructuring of the practice visit. Integrating evidence-based guidelines into practice has not been not widely successful, creating multiple challenges to primary care physicians. However, this study proved that the CDC immunization schedule was effectively implemented in most practices, as shown in the improvement in vaccination rates for certain disease conditions. The success of integrating guidelines into practice might be attributable to the quality improvement component of this project. Other barriers to quality improvement were numerous and included a lack of standardized metrics, no alignment between quality improvement and reimbursement, the misconception that technology equates quality, and fear of errors in relation to litigation. Overcoming these barriers require a change in the culture of medicine.
Limitations for this study included the information bias of physician self report via the survey data, as survey respondents might have under-reported or overestimated behavior. There might also have been bias depending on who the physician chose to include on the practice team as well who abstracted the data for the practice. Because not all practices had EMRs, there was potential bias in collecting data by EMR or by paper. Practices that participated in this study might have had a greater interest in quality improvement or adult immunizations than the general primary care practice. Additionally, because of the timeline of the grant, data collection was closed in late January, which had potential to limit the amount of influenza vaccinations that might have been performed by these practices through typical flu season (late March). Secular trends (public health campaigns, varying infection rates in communities over the year, vaccine availability) might also have accounted for the increase in vaccination rates as seen in these data.
Overall, the results showed that the intervention via conference call coaching and educational program had an impact on physician immunization practice patterns. All practices used a team approach, which they felt was an integral part of their success in boosting immunization practices. As the knowledge scores did not differ significantly between before and after intervention, our study showed that knowledge is necessary but not sufficient. Practice change takes a team approach, one that is invested in quality and supported to improve their practice. Because this study did not include a control group, future research may evaluate practices that use a team approach with those who do not to more concretely determine the impact of the practice team on quality improvement work. More information is needed to explain what is happening in practices that use a team that would not be happening otherwise. This information would be beneficial for small practices that may find it hard to implement the team approach.
Discussion
Orienting a practice to promote adult vaccination showed improved adult vaccination rates in this and other studies. This required a culture shift and an investment of time for the practice, one that is becoming increasingly difficult given the current time constraints in primary care practice. All practices reported spending between 12 and 72 hours on this program over the course of approximately 12 months. Analyses revealed no significant difference at the practice level between immunization rates and the number of hours the practice spent on the program. Additionally, when the effect of EMR status on vaccine delivery was evaluated, there was no association with EMR status and improved vaccination rates. These data might help persuade smaller practices that do not have as many resources to try quality improvement, as this program showed it could be effective in paper-based practices and with minimal time allotted.
An integral part of the practice's success was the development of the practice team. The value of the practice team meeting on a continual basis to review their quality improvement progress was vital to the success of any quality improvement work, and was demonstrated in other studies. Practice redesign in this program required a shifting of responsibilities among individuals in a practice in an effort to streamline activities and responsibilities and better orient the practice toward the patient's health. The team was taught in the coaching calls to share responsibilities to accomplish a common goal. Quality improvement faculty stressed the value of a practice champion who oversaw the quality improvement work and worked to motivate the group. All physicians in this study valued this role, and reported integrating advice from the practice team into their practice improvement work. Similar to other practice teams reported in the literature, this program required the individuals to surrender a small percentage of their autonomy to better serve the goals of the practice as a whole. For instance in 1 practice, the physician gave up the task of screening, passing this responsibility on to the nurse, allowing the physician more time to counsel the patient on the benefits of immunization. As the burden of chronic disease is increasing in our population, physicians are managing more and more complex patients, needing more time in the clinical encounter. These complex patients are often recommended various immunizations because of the susceptibility their disease invokes on the immune system. Few guidelines exist that offer recommendations on treating multiple chronic conditions. In light of these increasing challenges, the team approach is becoming a valuable mode of delivering comprehensive care to these complex patients by re-prioritizing responsibilities among the practice team.
It is difficult to anticipate vaccine demand, making it harder to decide what amounts to purchase. This creates a financial risk for the practice upfront without being able to appropriately anticipate what the demand will be. A recent study evaluated physicians' rationale behind the purchase of vaccinations and revealed that for herpes zoster, Tdap, and hepatitis B, many did not stock these vaccines because of their high inventory cost, associated low reimbursement, and inconsistent insurance coverage. Because only approximately 20% of internal medicine physicians carry all recommended adult vaccinations, it is not surprising that adult vaccination rates are subpar. Interestingly, in this study, the rates of Td/Tdap increased significantly across various measures from before to after intervention. Additionally, physicians administered herpes zoster, Tdap, and hepatitis B at more annual visits after intervention, suggesting either they made better use of their vaccine supply or increased their vaccine supply. Further data would be needed to understand this increase. Still, only a third of physicians in this study kept a supply of hepatitis B, and even fewer maintained supplies of hepatitis A, herpes zoster, human papilloma virus, and meningococcal vaccinations. Adequate supply of adult vaccinations is important to the health of the population. Therefore, it is not only imperative that physicians be reminded to recommend vaccinations, but to stock them as well.
Immunizations were fundamental to the success of health promotion of the population. However, our current system is oriented toward managing disease, with few resources targeted toward prevention. Other studies, like this one, found that a physician self-reported barrier to adult immunizations was insurance coverage. This might create a bias to refrain from suggesting immunizations to patients whom the physician suspected did not have insurance coverage for them. Another potential reason for low immunization rates among adults might be that most physicians provided immunizations at well visits, which occur annually at best. Results from this study showed that the majority of vaccinations occurred at annual well visits; a smaller percentage occurred at follow-up visits, and very few occurred at acute visits. Immunizations should be recommended at well and sick visits, requiring a restructuring of the practice visit. Integrating evidence-based guidelines into practice has not been not widely successful, creating multiple challenges to primary care physicians. However, this study proved that the CDC immunization schedule was effectively implemented in most practices, as shown in the improvement in vaccination rates for certain disease conditions. The success of integrating guidelines into practice might be attributable to the quality improvement component of this project. Other barriers to quality improvement were numerous and included a lack of standardized metrics, no alignment between quality improvement and reimbursement, the misconception that technology equates quality, and fear of errors in relation to litigation. Overcoming these barriers require a change in the culture of medicine.
Limitations for this study included the information bias of physician self report via the survey data, as survey respondents might have under-reported or overestimated behavior. There might also have been bias depending on who the physician chose to include on the practice team as well who abstracted the data for the practice. Because not all practices had EMRs, there was potential bias in collecting data by EMR or by paper. Practices that participated in this study might have had a greater interest in quality improvement or adult immunizations than the general primary care practice. Additionally, because of the timeline of the grant, data collection was closed in late January, which had potential to limit the amount of influenza vaccinations that might have been performed by these practices through typical flu season (late March). Secular trends (public health campaigns, varying infection rates in communities over the year, vaccine availability) might also have accounted for the increase in vaccination rates as seen in these data.
Overall, the results showed that the intervention via conference call coaching and educational program had an impact on physician immunization practice patterns. All practices used a team approach, which they felt was an integral part of their success in boosting immunization practices. As the knowledge scores did not differ significantly between before and after intervention, our study showed that knowledge is necessary but not sufficient. Practice change takes a team approach, one that is invested in quality and supported to improve their practice. Because this study did not include a control group, future research may evaluate practices that use a team approach with those who do not to more concretely determine the impact of the practice team on quality improvement work. More information is needed to explain what is happening in practices that use a team that would not be happening otherwise. This information would be beneficial for small practices that may find it hard to implement the team approach.
Source...