Can provider education or computerized standing orders increase rates of vaccination among elderly hospital patients?

In two different studies, an intensive educational intervention for physicians at one hospital and a computerized standing orders program at another hospital were associated with increased rates of vaccination among eligible patients.

Why is this important?

One-third to one-half of elderly Americans are not vaccinated against influenza and pneumococcal disease as recommended (NCHS 2005). To improve vaccination rates, public health and medical experts recommend vaccinating patients at risk for vaccine-preventable disease when they are hospitalized (ACIP 1997; Harper et al. 2005; Mandell et al. 2003; Niederman 2001).

Many elderly patients hospitalized with pneumonia have been admitted to the hospital before, which suggests that a hospital stay provides a good opportunity to identify those who should be vaccinated to help prevent future hospitalizations (Fedson et al. 1990). Yet only one-third of Medicare patients are screened for or receive an influenza or pneumococcal vaccination while hospitalized with pneumonia (AHRQ 2005), despite the fact that Medicare pays hospitals an additional fee for delivering vaccinations (ACIP 1997).

Based on evidence of effectiveness, the Medicare program permits—and experts recommend—the use of "standing orders" authorizing vaccination by nurses and pharmacists without a physician's examination and direct order (CDC 2003). Standing orders might be more efficient and effective when they are automated.

Interventions

Two different interventions are depicted: a provider educational intervention and an automated standing orders program.

1) Louisiana State University internal medicine primary caregivers ("house staff") initiated a year-long pneumococcal vaccine educational intervention at the Medical Center of Louisiana-New Orleans (Kruspe et al. 2003). Activities included:

• lectures reviewing the benefits and indications of pneumococcal and other commonly accepted vaccinations,
• reinforcement of these concepts at monthly physician orientation meetings, and
• posted reminders for pneumococcal vaccination.

2) Wishard Memorial Hospital, an Indianapolis-based county teaching hospital, compared the effectiveness of computer-generated standing orders to physician reminders, which had previously been found to increase physician ordering of influenza and pneumococcal vaccination (Dexter et al. 2001). Physicians on six general medicine wards were randomly assigned to intervention teams and admitted patients were sequentially assigned to teams. Patients eligible for vaccination were identified by a computerized protocol (Dexter et al. 2004).

• Physician reminders occurred daily and at patient discharge as part of a computerized physician order-entry system, allowing physicians to order vaccines with a single keystroke.
• Nurses were alerted to computer-generated standing orders for vaccination at patient discharge in the same way as they were alerted for physician orders. Nurses were trained on the vaccination protocol.

For both interventions, nurses interviewed all patients for whom vaccines were ordered and withheld vaccination if the patient reported a vaccination allergy or a prior vaccination in the appropriate time frame or refused the vaccination.

Findings

1) In the educational intervention study, screening to determine vaccination status increased by 60 percentage points among all pneumonia patients and by 72 percentage points among elderly pneumonia patients. The proportion who received the pneumococcal vaccination increased by 31 percentage points among all patients and by 34 percentage points among elderly patients (Kruspe et al. 2003).

2) In the randomized study of computerized interventions, vaccination rates for eligible patients whose nurses received standing orders at discharge were 12 to 22 percentage points higher than among patients whose physicians received reminders about vaccinations during their hospital stay. Most of the patients who were not vaccinated refused the vaccine (Dexter et al. 2004).

Implications

Educational initiatives for providers and patients in combination with standing orders might offer the most efficient and effective solution for improving vaccination rates among high-risk patients. The study authors noted that "standing orders for nurses could be much easier to carry out than physician reminders because the former can be implemented within nurse order management systems which are used widely in U.S. hospitals" (IUSM 2004).

Improvement Ideas and Resources

Additional resources on effective vaccination strategies can be found on the Web site of the Task Force on Community Preventive Services.

Measure:

1) The educational intervention included 435 patients hospitalized for pneumonia in the Louisiana State University Internal Medicine ward between July 2000 and June 2001 (pre-intervention) and July 2001 and June 2002 (post-intervention). Measures were the same as those used in the Medicare program. Patients who received nonacute care, transferred from another acute care facility, did not have pneumonia, or died while in the hospital were excluded from the analysis. There were no significant differences in patient demographics (age and sex) or length of stay between the pre- and post-intervention patients. All differences between the pre- and post-intervention groups shown in the chart were statistically significant (Kruspe et al. 2003).

2) The standing orders study included 3,777 general medicine patients cared for by 212 physicians and discharged from Nov. 1, 1998 through Dec. 31, 1999 (the intervention included influenza vaccination only during influenza season). Based on national guidelines, patients ages 65 and older were considered eligible for vaccination if they had a relevant chronic condition and there was no documentation of a vaccination in the relevant time period. A corrected denominator of truly eligible patients was determined by subtracting patients who reported a prior vaccination in the appropriate time frame (this proportion was determined for all patients in the standing orders group and imputed to the reminder group). There were no demographic or clinical differences between groups (Dexter et al. 2004).

Limitations:

Both studies were conducted in academic environments and might not be generalizable to other settings.

Source:

1) The educational intervention used patient records and was conducted by physicians and researchers at the Louisiana State University School of Medicine and Health Sciences Center and the Medical Center of Louisiana-New Orleans (Kruspe et al. 2003).

2) The standing orders study used data from a computerized questionnaire that nurses were required to complete for all patients receiving a vaccination order. It was conducted by researchers and physicians at Wishard Memorial Hospital, Indiana University School Medicine, the Regenstrief Institute, and the Veterans Affairs Medical Center, Indianapolis (Dexter et al. 2004).

References:

* Indicates source of data used in the chart(s).ACIP (Advisory Committee on Immunization Practices). 1997. Prevention of Pneumococcal Disease: Recommendations of the Advisory Committee on Immunization Practices. Morbidity and Mortality Weekly. Recommendations and Reports 46(RR-8): 1–24.

AHRQ (Agency for Healthcare Research and Quality). 2005. National Healthcare Quality Report, 2005. AHRQ Publication No. 06-0018. Rockville, Md.: U.S. Department of Health and Human Services.

CDC (Centers for Disease Control and Prevention). 2003. Facilitating Influenza and Pneumococcal Vaccination Through Standing Orders Programs. Morbidity and Mortality Weekly. Recommendations and Reports 52(4): 68–9.

Dexter, P. R., S. Perkins, J. M. Overhage et al. 2001. A Computerized Reminder System to Increase the Use of Preventive Care for Hospitalized Patients. New England Journal of Medicine 345 (13): 965–70.

* Dexter, P. R., S. M. Perkins, K. S. Maharry et al. 2004. Inpatient Computer-Based Standing Orders vs Physician Reminders to Increase Influenza and Pneumococcal Vaccination Rates: A Randomized Trial. Journal of the American Medical Association 292 (19): 2366–71.

Fedson, D. S., M. P. Harward, R. A. Reid et al. 1990. Hospital-Based Pneumococcal Immunization. Epidemiologic Rationale from the Shenandoah Study. Journal of the American Medical Association 264 (9): 1117–22.

Harper, S. A., K. Fukuda, T. M. Uyeki et al. 2005. Prevention and Control of Influenza. Recommendations of the Advisory Committee on Immunization Practices (ACIP). Morbidity and Mortality Weekly. Recommendations and Reports 54 (RR-8): 1–40.

IUSM (Indiana University School of Medicine). 2004. Computer Assisted Standing Orders Improve Adult Immunization Rates. Press release. Indianapolis, Ind.: Indiana University.

* Kruspe, R., R. Lillis, D. W. Daberkow, 2nd et al. 2003. Education Does Pay Off: Pneumococcal Vaccine Screening and Administration in Hospitalized Adult Patients with Pneumonia. The Journal of the Louisiana State Medical Society 155 (6): 325–31.

Mandell, L. A., J. G. Bartlett, S. F. Dowell et al. 2003. Update of Practice Guidelines for the Management of Community-Acquired Pneumonia in Immunocompetent Adults. Clinical Infectious Diseases 37 (11): 1405–33.

NCHS (National Center for Health Statistics). 2005. Health United States, 2005. Hyattsville, Md.: Centers for Disease Control and Prevention.

Niederman, M. S. 2001. Guidelines for the Management of Community-Acquired Pneumonia. Current Recommendations and Antibiotic Selection Issues. The Medical Clinics of North America 85 (6): 1493–509.