RESEARCH

ORIGINAL
Family Medicine and Community Health
ORIGINAL RESEARCH

Adult immunization improvement in an underserved family medicine

practice
Mohamad Sidani, Jaden Harris, Roger J. Zoorob

Abstract Department of Family and

Objective: Vaccines prevent many cases of infectious disease, yet immunization campaigns Community Medicine, Baylor
are hindered by various barriers. This work presents the results of a quality improvement project College of Medicine, Houston,
addressing barriers to vaccine compliance in an underserved teaching practice by reducing missed TX, USA
opportunities and increasing provider and patient compliance rates for pneumococcal, Tdap,
CORRESPONDING AUTHOR:
influenza, and zoster vaccines in adults.
Roger J. Zoorob, MD, MPH
Methods: The study intervention aimed to address patient knowledge, provider knowledge
Department of Family and
and skills, proactive care coordination, and outreach and counselling of high-risk groups. Aggre- Community Medicine, 3701 Kir-
gate patient data from intervention at year-end were compared to the prior year. Outcome targets by Drive, Suite 600, Houston, TX
were as follows: improved vaccination rates by one-half of the difference between baseline and 77098, USA
Healthy People 2020 goals; reduced patient refusals by 10%; and reduced missed opportunities Tel.:+713-798-2333
by 50%. E-mail: [email protected]
Results: All of the vaccination rates improved, but with mixed results regarding the target
Received 25 March 2015;
outcomes. The rates of vaccine refusal were mixed in terms of the direction of the change, the
Accepted 20 April 2015
significance, and achieving targets. Missed opportunities all improved, but the significance was
mixed and none reached targets.
Conclusion: This project has helped to identify patient and provider knowledge of vacci-
nation as a key to increasing compliance, and missed opportunities as the greatest challenge in
achieving targets. The burden of documentation is significant on providers, and future work should
focus on methods to improve the ease of documentation. Clinical outcomes and improvements
were encouraging; however, it is clear that there remain challenges to reaching Healthy People
2020 goals within the study population and nationally.

Keywords: Immunization; vaccine; practice improvement; pneumococcal; Tdap; influenza;

zoster

Introduction an important US public health effort to pro-

Vaccines are among the greatest advances in mote health, reduce disparities, and advance
modern medicine, and have prevented many research. Among the objectives of HP2020
cases of infectious diseases, yet vaccination is to: Reduce, eliminate, or maintain elimi-
campaigns are hindered by various barriers and nation of cases of vaccine-preventable dis-
require consistent evaluation and innovation. eases [1]. The influenza (flu) vaccine is
The Healthy People 2020 (HP2020) program is an example of an effective, but underused

Family Medicine and Community Health 2015;3(2):272

www.fmch-journal.org DOI 10.15212/FMCH.2015.0114
2015 Family Medicine and Community Health
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Sidani et al.

immunization. Even though vaccines are widely available, to decrease such reactions [7]. One unresolved concern is that
affordable, and efficacious, influenza continues to take a dra- influenza vaccine may cause Guillain-Barr syndrome, and
matic toll on the unvaccinated each year, impacting high-risk research into this association is ongoing [9].
populations and the elderly with hospitalization, death, and The current study is the result of a quality improvement
economic burden [2, 3]. project designed to systematically address perceived barriers
Barriers to immunization compliance are numerous, to adult vaccine compliance in an underserved teaching prac-
including knowledge and attitudes of patients and providers, tice. This was accomplished by reducing missed opportunities
economic concerns, access to care [2, 3], and racial disparities and increasing both provider and patient knowledge and com-
[4]. Many practices face challenges to provider compliance pliance. Similar to national rates, the baseline immunization
with evidence-based guidelines, including lack of awareness rates at the study practice were low compared to HP2020 goals
or familiarity with guidelines, lack of agreement, lack of [1], and therefore represented an opportunity for improvement.
self-efficacy and outcome expectancy, and external barriers, The intervention aimed to improve immunization rates over
including patient and environmental factors [4]. Situational the course of 1 year by enhancing provider and patient knowl-
constraints, such as presenting illness, also limit the ability edge, soliciting and addressing patient concerns, and reduc-
of providers to administer vaccines during a given clinical ing missed clinical opportunities. Although the HP2020 goals
encounter. Teaching practices face additional challenges, as cover a wide range of infectious diseases for all age groups,
medical residents may not assign high priority to adult immu- this work focused on rates of pneumococcal, Td or Tdap, influ-
nizations because vaccines may be not highly valued or the enza, and zoster vaccines in adults.
use of vaccines closely monitored [3].
Other common reasons patients forego vaccination include Methods
the belief that healthy people do not need vaccinations, con- The study was a quality improvement project conducted in an
cerns over side effects, and reporting that their physician did underserved urban family medicine residency practice from
not recommend vaccinations [5]. Indeed, only one-fourth of July 2012 through June 2013. Age at the time of the visit deter-
primary care physicians issued influenza vaccination remind- mined inclusion in the appropriate vaccine age groups used. The
ers during the 20112012 influenza season [6]. Patient fear of influenza vaccine rate was calculated by administration of at
vaccine risk is also a factor in declining recommended vac- least 1 dose during the influenza season of the 12-month assess-
cines. For example, a common concern is that the influenza ment period, although pneumococcal polysaccharide (PPSV),
vaccine can cause the flu; however, inactivated influenza vac- herpes zoster, and tetanus (Td and Tdap) booster vaccines
cine does not cause the flu, although injection site swelling, were limited to visits during the calendar year, and required
redness, and tenderness are possible [7]. Although the live- investigation of broader appropriate timeframes for immuniza-
attenuated nasal spray flu vaccine contains live virus and has a tion history. The inclusion groups for each vaccine varied by
greater potential for side effects, the live-attenuated nasal spray appropriate guidelines and age groups defined by the funding
flu vaccine does not cause influenza either [8]. This common source, which varied slightly from HP2020. The study popu-
misconception may be partially attributable to the concurrent lation was adults >19 years of age assessed for influenza vac-
onset of other seasonal illnesses, perceived as flu, following cine needs during the typical flu season. Adults >65 years of
vaccination [2]. Similarly, misconceptions about mercury tox- age were assessed for a single lifetime dose of PPSV on record.
icity in vaccine formulations are prevalent [2]. Concerns about Adults 1964 years of age were assessed for a recorded Td or
egg allergies remain, but such myths have been diminished by Tdap immunization in the past 10 years. Finally, a single life-
recent studies [6]. Risk of adverse reactions is higher in aller- time dose of zoster vaccine was assessed for adults >60years of
gic or immunocompromised patients, and also in young chil- age. The study clinics (hereafter referred to as clinics) are des-
dren. The Centers for Disease Control and Prevention (CDC) ignated as medically-underserved by the US Health Resources
recommends screening and using evidence-based precautions and Services Administration (HRSA). The specific patient

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Adult immunization improvement in family practice

population tends to be the most underserved members within addressing their fears and misconceptions. This goal was
these communities, predominantly uninsured, underinsured, or broken down into passive and active patient education com-
publicly insured, and primarily members of minority communi- ponents. The passive component included the development by
ties. Specifically, the rate of self-pay was 8.6%, publicly insured the Vaccine Task Force of a set of educational pamphlets and
was 53.4%, and charity care offered by the affiliated hospital waiting room posters to increase patient knowledge regard-
system was 10.3%. The racial distribution was approximately ing the need for and safety of vaccines in adults, and mail-
53% African American, 30% Latino, and 17% Caucasian. ing vaccine reminder letters to patients. The active component
These demographics owe in part to the geographic locations of involved encouraging providers to counsel their patients on
clinics and acceptance of public insurance options, along with the importance of vaccinations, and to respond to patient fears
sliding-scale payment and charity fee schedules. and misconceptions. This encouragement was delivered in the
The intervention plan consisted of two goals. The first form of discussion as a standing item in the weekly clinical
goal was to reduce the overall rate of missed opportunities to management meetings via dedicated residency didactic ses-
administer vaccines by one-half of the difference between the sions, and by the ongoing presence of program champions,
HP2020 goals and baseline. This goal was divided into two including the medical director, nurse manager, and resident
elements: teamwork and training. For the teamwork compo- project leader.
nent, a team-based approach was used to optimize care coor- Data was collected using a reporting tool (SAP Crystal
dination and case management strategies at point-of-service Reports) to query a clinical electronic health record system.
and through outreach to high-risk groups, including older This reporting included all patient records queried from the
adults and patients captured in clinical disease registries. A Health Maintenance Table section of the patient record for
vaccines task force consisting of key operational stakehold- inclusion groups seen in the clinics during the year previous
ers met monthly to discuss strategy and progress. This team to the study implementation. The rates of vaccinated adults
included the department chair, medical director, nurse qual- >19 years of age with Tdap and influenza, PPSV for adults
ity manager, project manager, and a resident physician trainee >65 years of age, and zoster for adults >60 years of age were
champion. Other members of the clinical team were present used for baseline. Reports were compiled and analyzed by
at clinical operations meetings and were invited to contribute the Quality Assurance (QA) team to determine baseline rates
feedback. The team developed patient outreach methods which of immunization and the difference between baseline rates
combine annual reminder notices sent by mail, educational and HP2020 goals. At the end of the study year, data for all
pamphlets and waiting room posters, limited annual appoint- adults seen in clinics during that year defined the ending rates.
ment solicitation phone calls, and verbal counselling to high- De-identified lists were used to aggregate all data points. Data
risk groups. Proactive care coordination was implemented by analysis was conducted using a simple Z-test for proportions
the quality nurse and support staff to help ensure that patient with significance set at a 95% confidence level.
charts were reviewed before or during each visit, opportunities
for vaccination were identified, vaccines administered, neces- Results
sary counselling provided, and accurate records maintained. Outcome evaluations were based on several parameters, and
Standing orders for nursing staff were put in place for influ- split into administrative processes and clinical outcomes.
enza and PPSV vaccines. An additional training component Administrative process outcomes included the frequency of
introduced two new dedicated didactic sessions per year which team meetings held, the number of didactic sessions held,
aimed to increase faculty and resident awareness of evidence- and completion of educational materials and outreach to
based guidelines, proper documentation processes, and patient patients. These measures are perhaps the simplest to control,
counselling methods. record, and improve, yet are essential in the overall project
The second goal was to improve overall patient compli- design. Each of these measures reached targets set, includ-
ance by educating patients about the need for vaccines and ing monthly dedicated team meetings and a regular agenda

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item in clinical management meetings, successful integration end result was 73.9% (an improvement of 9.1%). This finding
of 2 yearly didactic sessions, completion and use of educa- was also significant, but fell short of the target of 77.4%. The
tional posters and pamphlets for patient waiting rooms, and a baseline Td or Tdap for adults 1964 years of age was 40.3%
mass mailing of immunization reminders to high-risk patient and the end result was 52.8% (an improvement of 12.5%). This
groups. finding was significant and considered another encouraging
Clinical outcome measures for this project were the rate result, but we did not set a target for Td or Tdap because there
of vaccine administration, rate of patient refusals, and rate of was no HP2020 goal for Tdap. Finally, the baseline admin-
missed opportunities determined by the number of patients istration of zoster vaccine was 15.2% and the end result was
seen without any recorded status regarding the recommended 23.0% (an improvement of 7.8%). This result was also signifi-
vaccines. The outcome targets were to improve vaccine admin- cant and slightly exceeded the target of 22.6%.
istration rates by one-half the difference between baseline and The rates of patient refusal for vaccines were mixed with
HP2020 goals, reduce patient refusals by 10% from baseline, respect to the direction of change, significance, and reaching
and reduce clinical missed opportunities by 50% from base- the 10% reduction target. The baseline refusal rate for influ-
line. An overview of clinical outcomes is shown in Table 1. enza was 14.5% and the end refusal rate post-intervention
Vaccination rates improved, but with mixed results was 11.1%, which was a significant improvement of 3.4% and
with respect to reaching the target of one-half the differ- exceeded the 10% target of reduction of 13.1%. The baseline
ence between baseline and HP2020 goals for each vaccine. refusal rate for PPSV was 9.9% and the end result was 9.2%
Baseline influenza vaccine administration for adults >19 years (a 0.7% improvement). This result was not significant, nor did
of age during the flu season (20122013) was 24.4% and the it reach the target of 8.9%. The baseline refusal rate for Td or
post-intervention result was 35.2% (an overall improvement Tdap was 6.8% and the end result was 6.9%; this result was
of 10.8%). Although this was a significant and encouraging actually slightly worse than baseline, but the difference was
improvement, it did fall far short of the target of 47.2%. The not significant. The target was 6.1%. The baseline refusal rate
baseline PPSV for adults >65 years of age was 64.8% and the for zoster was 20.9% and the end result was 15.4%, which was

Table 1. Overview of clinical outcomes

Outcome Baseline (%) (n) End (%) (n) Change Significant? Target Target reached?

Vaccine administered
Influenza 24.4% (3400) 35.2% (2291) 10.8% Improvement Yes 47.2% No
PPSV 64.8% (213) 73.9% (184) 9.1% Improvement Yes 77.4% No
Zoster 15.2% (421) 23.0% (370) 7.8% Improvement Yes 22.6% Yes
Tdap/Td 40.3% (3148) 52.8% (2107) 12.5% Improvement Yes N/A N/A

Vaccine refused
Influenza 14.5% 11.1% 3.4% Improvement Yes 13.1% Yes
PPSV 9.9% 9.2% 0.7% Improvement No 8.9% No
Zoster 20.9% 15.4% 5.5% Improvement Yes 18.8% Yes
Tdap/Td 6.8% 6.9% 0.1% Decline No 6.1% No

Missed opportunity
Influenza 61.1% 53.7% 7.4% Improvement Yes 30.5% No
PPSV 25.4% 16.8% 8.6% Improvement Yes 12.7% No
Zoster 63.9% 61.6% 2.3% Improvement No 31.9% No
Tdap/Td 52.9% 40.2% 12.7% Improvement Yes 26.5% No

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a significant improvement of 5.5% and exceeded the target of >60years of age has a national administration rate of 6.7%
18.8%. and a HP2020 target of 30%. In 2012, the percentage of adults
Missed opportunities all improved, but significance was >19 years of age who received Tdap in the previous 7 years
mixed, and none reached the target of a 50% reduction from was approximately 14.2%; however, there was no associated
baseline. The baseline missed opportunity rate for influenza HP2020 goal for Tdap vaccination [3].
was 61.1%, and the end result was 53.7%, which was a sig- Chatterjee and OKeefe [12] suggested that because of
nificant improvement of 7.4% (target=30.5%). The baseline the successes of immunizations in recent decades and fading
missed opportunity rate for PPSV was 25.4%, and the end memory of the incidence of some diseases, there appears to be
result was 16.8%, which was a significant improvement of 8.6% a shift away from the fear of disease to a fear of vaccines. This
(target=12.7%). The baseline missed opportunity rate for Td or is evidenced by the public controversies surrounding parents
Tdap was 52.9%, and the end result was 40.2%, which was a and even healthcare providers opting not to vaccinate children
significant improvement of 12.7% (target=26.5%). The base- and themselves based on common misconceptions [12, 13].
line missed opportunity rate for zoster was 63.9%, and the end The intervention in this study was aimed in part to address
result was 61.6%, which was an improvement of 2.3%. This this phenomenon.
result was neither significant nor reached the target of 31.9%. Our results were generally encouraging, indicating the
Our study showed that the pre-visit review by the QA nurse value of a dual-pronged approach to adherence, thus address-
had significant changes in refusals and missed opportunities ing both provider and patient needs. Barriers to vaccine
regarding the influenza vaccination (Table 2). It has been administration prevalent in the literature were also factors in
shown that standing orders for nurse recommendations are a this situation, and attempts to address the barriers produced
significant patient motivator, further enhanced by physician modest gains. An overall evaluation of clinical outcomes
follow-up [10, 11]. yielded mixed results in each aspect of our assessment, as
This study was conducted as a retrospective review of out- vaccination, refusal, and missed opportunity rates improved
comes from a clinical and training quality improvement pro- overall, but varied within each vaccine group and many fell
ject. As such, the study was granted exemption from human short of targets.
subjects research requirements by the Baylor College of This study had several limitations. The program addressed
Medicine Institutional Review Board. multiple interventions, including physician and patient edu-
cation, standing orders for influenza and pneumococcal
Discussion vaccines, better record keeping, and targeting missed oppor-
Nationally, influenza vaccination among adults is estimated to tunities. Although each factor worked toward the ultimate suc-
be less than 40% in the 20102011 and 20112012 flu sea- cessful outcomes seen in the project, it is difficult to evaluate
sons, although the HP2020 goal is 70% [1]. Similarly, the rates the effect of each factor independently. Moreover, the study
of other common adult immunizations are suboptimal. For was limited to urban underserved practices, and this may limit
example, PPSV coverage among non-institutionalized adults generalization of the results to other settings. It is also worth
>65 years of age is 60% overall, although the HP2020 goal noting that the study was conducted over a single year in a
is 90% [1]. The shingles (herpes zoster) vaccine for adults residency training practice. Another limitation was the use of

Table 2. Effect of proactive quality assurance on influenza vaccination rates

Effect Proactive care (n=140) Usual care (n=500) % Change p Value

Administered 60% 57% 3% Improvement ns

Refused (of asked) 27% (n=116) 20% (n=356) 7% Decline <0.05
Missed opportunity 17% 29% 12% Improvement <0.05

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de-identified aggregate data, thus the impact of interventions topics-objectives/topic/immunization-and-infectious-diseases/

on individual compliance was not measurable. In addition and objectives.
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Conflict of interest 10. Daniels NA, Gouveia S, Null D, Gildengorin GL, Winston CA.
The authors declare no conflict of interest. Acceptance of pneumococcal vaccine under standing orders by
race and ethnicity. J Natl Med Assoc 2006;98(7):108994.
Funding 11. Zimmerman RK, Nowalk MP, Tabbarah M, Hart JA, Fox DE,

This work was funded by the 2013 American Academy of Raymund M. Understanding adult vaccination in urban, lower-
socioeconomic settings: influence of physician and prevention
Family Physicians Foundation Pfizer Immunization System
systems. Ann Fam Med 2009;7(6):53441.
Implementation Award.
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