Reports From the Field

Lessons Learned from a Quality Improvement Project to Reduce Missed Opportunities to Vaccinate Adults

Journal of Clinical Outcomes Management. 2015 September;22(9)

Author(s):

References

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From Abington Health, Abington, PA (Ms. Walter) and Duquesne University School of Nursing, Pittsburgh, PA (Dr. Guimond).

Abstract

Background: National coverage rates for many recommended adult vaccines are low. Tetanus toxoid, diphtheria, and acellular pertussis (Tdap) and pneumococcal vaccination rates among adults are 20% and 16%, respectively. To address these low rates in our practice, we identified missed opportunities for vaccination as a target for improvement.
Objective: To examine the effectiveness of a vaccine reminder checklist at the point of care and assess providers’ perceived vaccine practices.
Methods: The quick sample method was used to assess pre- and post-intervention pneumococcal polysaccharide (PPSV) and Tdap vaccination rates among the target population (adults 18-64 for Tdap; high-risk adults 18-64 for PPSV). A post-intervention survey was used to assess providers’ adult vaccination practices and their opinion of the reminder tool.
Results: The Tdap vaccination rate did not change and was constant at 47%. PPSV vaccination rates decreased from 50% to 40%. Among the providers, 47% reported ordering immunizations at sick visits, as compared to 76% at follow-up visits. The providers reported the reminder checklist was useful for determining a patient’s eligibility for a vaccine.
Conclusion: No improvement in vaccination rates was detected for this project, which may be partially explained by challenges originating at patient check-in. In the future, buy-in from all staff in our practice setting will be sought. Results indicate that providers may hesitate to administer immunizations at sick visits and may need education on vaccination contraindications.

Vaccines are an important public health tool that offer safe and effective protection against certain diseases and reduce the health care burden [1,2]. Missed opportunities to vaccinate, defined as any primary care encounter in which a patient eligible for a vaccine is not administered a vaccine, lead to suboptimal immunization coverage among adults. Providers have been urged to review patients’ vaccine status at every patient encounter [3]. Rates of vaccinations recommended in 2012 by the Advisory Committee on Immunization Practices (ACIP) remain low [4], particularly coverage rates for tetanus toxoid, diphtheria, and acelluar pertussis vaccine (Tdap) vaccine among adults, and for pneumococcal polysaccharide vaccine (PPSV) among high-risk adults [2]. Nationally, uptake rates are approximately 16% for Tdap and 20% for pneumococcal vaccines among eligible adults aged 18 to 64 years [5]. These low uptake rates suggest that programs are needed to reduce missed opportunities to vaccinate and improve vaccination rates among adults.

There is a strong case for improving Tdap and pneumococcal vaccination uptake among high-risk adults. Since the 1970s, the incidence of pertussis in the United States has increased substantially, with numbers of reported cases reaching as high as 48,277 and 28,639 in 2012 and 2013, respectively [2]. Some states experienced epidemic levels of pertussis [2,6]. Pertussis is often fatal among infected infants, and infection in adolescents and adults may cost upwards of $800 per case [7,8]. In 2005, high-risk adults for whom the PPSV was indicated accounted for half of the 40,000 pneumococcal infections in the United States [9]. PPSV boasts a 50% to 80% effectiveness rate in preventing pneumococcal disease among high-risk patients [9]. In a CDC cost-effectiveness analysis, immunization of immunocompromised patients with the pneumococcal conjugate vaccine (PCV-13) at the time of diagnosis followed with PPSV vaccinations starting 1 year later led to savings of $7.6 million, added 1360 quality-adjusted life years, and prevented 57 cases of invasive pneumococcal disease [10].