USE OF INTRANET AND OTHER INTERVENTIONS TO INCREASE INFLUENZA VACCINATION AMONG HEALTH CARE WORKERS

Chris Ferris, MAUniversity of Texas

School of Public HealthApril 14, 2011

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Influenza (the Flu)

• Serious respiratory illness• Epidemics occur annually• 3-5 million cases worldwide• 500,000 deaths

SOURCE: “Seasonal Influenza: The Disease.” Centers for Disease Control and Prevention: http://www.cdc.gov/flu/about/disease/index.htm.

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Impact in the United States

• 200,000 hospitalizations• 36,000 deaths

SOURCE: “Seasonal Influenza: The Disease.” Centers for Disease Control and Prevention: http://www.cdc.gov/flu/about/disease/index.htm.

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Prevention

• Virus mutates every year

• Vaccination• Frequent hand

washing

SOURCE: "Prevention and Control of Influenza: Recommendations of the Advisory Committee on Immunization Practices (ACIP)." MMWR. 54(RR08); July 29, 2005.http://www.cdc.gov/MMWR/PREVIEW/MMWRHTML/rr5408a1.htm.

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Health Care Workers (HCWs)

• Can pass virus to patients and other staff

• Influenza infections low vaccination rates among HCWs

SOURCES: "Influenza Vaccination of Health-Care Personnel: Recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Advisory Committee on Immunization Practices (ACIP)." MMWR. 55(RR02);1-16: February 24, 2006: http://www.cdc.gov/MMWR/PREVIEW/MMWRHTML/rr5502a1.htm.

Elder AG, O’Donnell B, McCruden EA, Symington IS and Carman WF. “Incidence and recall of influenza in a cohort of Glasgow healthcare workers during the 1993-4 epidemic: results of serum testing and questionnaire.” BMJ; 313(7067): 1241-2.

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Policy Recommendations

SOURCES: “Prevention & Control of Influenza - Recommendations of the Advisory Committee on Immunization Practices (ACIP).” MMWR Jul 13, 2007; 56(RR06): 1-54.

Lugo, N. “Will carrots or sticks raise influenza immunization rates of health care personnel?” American Journal of Infection Control. February, 2007; Vol. 35, No. 1: 1.

• CDC: Health care facilities “should offer influenza vaccinations to all” health care personnel

• The Joint Commission: Require organizations to track employee vaccination rates

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Vaccination Rates among HCWs

2001-02

2002-03

2003-04

2004-05

2005-06

2006-07

2007-08

0%

10%

20%

30%

40%

50%

60%

38%40% 42%

33%

42%45%

48%

21%22% 23%

16%20% 21% 24%

Health Care WorkersUS Adults (18-64)

SOURCE: The Centers for Disease Control and Prevention: “Self-reported influenza vaccination coverage trends 1989 - 2008 among adults by age group, risk group, race/ethnicity, health-care worker status, and pregnancy status, United States, National Health Interview Survey (NHIS).” http://www.cdc.gov/flu/professionals/vaccination/pdf/NHIS89_08fluvaxtrendtab.pdf.

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Mandatory Vaccinations?

SOURCES: “Policy Statement—Recommendation for Mandatory Influenza Immunization of All Health Care Personnel.” Committee on Infectious Diseases, Pediatrics; published online Sept. 13, 2010: http://pediatrics.aappublications.org/cgi/reprint/peds.2010-2376v1.

Stein R. “Mandatory Flu Shots Hit Resistance.” The Washington Post. Sept. 26, 2009.

• H1N1 Influenza spurred some to mandate vaccine

• AAP: “Mandatory programs for all [health care personnel] should be implemented nationwide”

• Most hospitals and other health care facilities do not mandate vaccination

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Economics

SOURCES: Folland S, et al. The Economics of Health and Health Care. Upper Saddle, NJ: Prentice Hall; 2001: 8.

Camerer C. “Behavioral Economics: Reunifying Psychology and Economics.” Proc. Natl. Acad. Sci. Sept. 1999; 96: 10575, 10577.

• Traditional economics– Assumes decision-maker is rational– “Making the best choices that further one’s own ends”– Because rational people make few mistakes, policies aren’t

necessary to help them• Grossman’s theory of human capital

– Individuals invest in themselves– Trade current utility for future utility

• Behavioral economics– Relaxes rationality assumptions– Allows for “non-rational” factors

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Behavioral Economics

SOURCES: Shumaker SA, Ockene JK and Reikert KA. The Handbook of Health Behavior Change. Hamilton Printing Company, New York; 2009: 21.

Richman B. “Behavioral economics and health policy: understanding Medicaid's failure.” Cornell Law Review. Mar 2005; 90(3): 722.

• What non-rational factors influence decisions?– Health information can lead to improved health

behaviors– Limited success

• Theory of Reasoned Action – Education is not enough– Intention also determines behavior

• Attitude toward behavior• Subjective norms associated with behavior

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Behavioral Economics

SOURCE: Shumaker SA, Ockene JK and Reikert KA. The Handbook of Health Behavior Change. Hamilton Printing Company, New York; 2009: 21.

• Theory of Planned Behavior (TBP)– Attitude toward the behavior– Subjective norms– Perceived behavioral control

• Apply TBP to influenza vaccination among HCWs

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Dissertation Aims

• Analyze and evaluate results of replication of Intranet intervention

• Conduct systematic review of literature to determine other ingredients for successful interventions

• Recommend policy changes to improve influenza vaccination rates among HCWs

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Journal Article I: Use of Intranet to Increase

Influenza Vaccination Among Health Care Workers

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Overview

• Objective: Evaluate effectiveness of Intranet intervention in increasing influenza vaccination level among HCWs

• Design/Methods: New intervention at non-profit, adult hospital which “required” employees to select vaccination status on Intranet. This tactic was accompanied by other, related interventions.

• Results: Statistically significant difference in percentage of employees vaccinated: 36.3% in previous year vs. 48.5% in intervention year (P<.001)

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Cleveland Clinic

• 2004-05 flu season: Cleveland Clinic used unique declination form on Intranet

SOURCE: Bertin M, Scarpelli M, Proctor AW, et al. “Novel use of the Intranet to document health care personnel participation in a mandatory influenza vaccination reporting program.” American Journal of Infection Control. February, 2007; Vol. 35, No. 1.

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Cleveland Clinic

• Mandatory but not enforced• 90% of HCWs participated• Vaccination rate improved from 38% to 55%• Replication of Intranet intervention at other

hospital

SOURCE: Bertin M, Scarpelli M, Proctor AW, et al. “Novel use of the Intranet to document health care personnel participation in a mandatory influenza vaccination reporting program.” American Journal of Infection Control. February, 2007; Vol. 35, No. 1.

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Intervention at St. Luke’s

• Similar to Cleveland Clinic• Oct. 2008 – Jan. 2009• Strategies:– Education and information– Free vaccine– Vaccine easily accessible– Online questionnaire– Pop-up window for declining employees– E-mails to managers

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Intervention at St. Luke’s

• Similar to Cleveland Clinic intervention• Draws on Theory of Planned Behavior– Education not enough– Intention is key determinant of behavior• Attitude• Subjective norms• Perceived behavioral control

SOURCE: Ajzen I and Fishbein M. Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice-Hall; 1980: 5.

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Theory of Planned BehaviorCommunication Methods Salient Messages TPB Dimensions

Wallpaper on computers “Flu doesn’t fight fair”“You can spread flu to coworkers, patients, family”

Subjective normAttitude toward behavior

Employee newsletter “Vaccine is best way to protect yourself and patients”“Free flu shots”Signed by CEO, PSO and CNO

Attitude toward behaviorPerceived behavioral controlSubjective norm

Employee Intranet “Vaccine is best way to protect yourself and patients”“All employees required to complete online questionnaire”

Attitude toward behaviorSubjective norm

E-mails to managers “Not too late”“Occupational Health giving free shots”Locations and times for free shots

Perceived behavioral controlSubjective norm

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Data Collection and Analysis

• Occupational Health: number of employees vaccinated

• Web Center: participation in online questionnaire • Human Resources: average number of

employees during intervention

• Statistical comparison of employees vaccinated to previous year using Pearson chi-square test (P<0.05)

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Results• Online Questionnaire: 42.68% participated • 40.02%: Received flu shot this year• 2.67%: Decline flu shot for medical reason• 0%: Choose not to be vaccinated

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Results• Overall Vaccination Level

Vaccinated (%)

Δ% compared to 2008-09 season

P value

Flu Season Yes No

2007-08 2,046 (36.3%)

3,595 (63.7%)

12.2% <0.005

2008-09 2,546 (48.5%)

2,702 (51.5%)

- -

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Results• Intranet intervention associated with increase

in vaccination rate among HCWs• Adds strength to Cleveland Clinic study

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Journal Article II: Use of Interventions to Promote

Influenza Vaccination Among American Health Care Workers:

A Systematic Review

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Overview

• Objective: Assess current interventions to determine which policies have been the most effective in increasing influenza vaccination rates among HCWs.

• Methods: Systematic review of research published between January 1994 and March 2010; studies found in Medline/Pubmed, Ovid and Ebsco databases were included.

• Results: Combination of several interventions may prove successful in improving vaccination rates among American HCWs.

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Systematic Review

• Analysis of existing literature• Examine which interventions associated with

increase in vaccination rates among HCWs• Identify active ingredients for successful

interventions

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Systematic Review

• Peer-reviewed journals Jan. 1994-Mar. 2010• Effects of interventions for increasing

influenza vaccination rates among HCWs• At hospitals, nursing homes, etc. in U.S.• Online databases:• Medline/Pubmed• Ovid• Ebsco

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Studies Included

• 21 studies met initial inclusion criteria• 9 dropped • 12 included for systematic review

Multiple-Arm Studies Pre-Post Studies

Zimmerman, et al. Ribner, et al.

Kimura, et al. Polgreen, et al. (2008)

Polgreen, et al. (2009) Bertin, et al.

Gazmararian, et al. Kuntz, et al.

Nicholson, et al.

Shah, et al.

Nace, et al.

CDC

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Interventions

• Strong administrative support• Free or no charge• More easily accessible• Education/information campaign• Declination/consent forms• Vaccine “champions” within organization• Incentives

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Multiple Arm Studies Author Population (N) Post-Intervention

Vaccination Rate %Intervention(s)

Zimmerman, et al. Non-clinical staff (969) 46.2 education

Non-clinical staff (7,015) 39.6 education, incentive

Indirect patient contact (412) 33.5 education

Indirect patient contact (888) 33.7 increased access, education

Indirect patient content (1,478) 43.3 education, incentive

Indirect patient contact (2,359) 37.9 increased access, education, incentive

Direct patient contact (1,247) 34.5 education

Direct patient contact (2,461) 39.0 increased access, education

Direct patient contact (3,904) 38.4 education, incentive

Direct patient contact (6,500) 41.4 increased access, education, incentive

Kimura, et al. All employees/Group D (754) 53 education, vaccine day, free vaccine

All employees/Group C (832) 46 vaccine day, free vaccine

All employees/Group B (821) 34 education

All employees/Group A (1517) 28 no intervention/control group

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Multiple Arm Studies Author Population (N) Baseline %

Change %Intervention(s)

Zimmerman, et al. Non-clinical staff (969) 40.1+6.1

education

Non-clinical staff (7,015) 34.6+5.0

education, incentive

Indirect patient contact (412) 30.5+3.0

education

Indirect patient contact (888) 28.3+5.4

increased access, education

Indirect patient contact (1,478) 32.8+10.5

education, incentive

Indirect patient contact (2,359) 32.0+5.9

increased access, education, incentive

Direct patient contact (1,247) 31.6+2.9

education

Direct patient contact (2,461) 30.2+8.8

increased access, education

Direct patient contact (3,904) 31.6+6.8

education, incentive

Direct patient contact (6,500) 31.1+10.3

increased access, education, incentive

Kimura, et al. All employees/Group D (754) 39+14

education, vaccine day, free vaccine

All employees/Group C (832) 35+11

vaccine day, free vaccine

All employees/Group B (821) 29+5

education

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Multiple Arm Studies Author Population (N) Vaccination rate % Intervention(s)

Polgreen, et al. (2009) Hospitals (79) +12.6 declination/consent form

Gazmararian, et al. Hospital 1 59 increased access, prioritized by employee type, quarantine after FluMist

Hospital 2 47 increased access, prioritized by employee type

Hospital 3 46 increased access, prioritized by employee type, employee families vaccinated

Hospital 6 39 increased access, quarantine after FluMist, declination/consent form

Hospital 7 38 increased access, prioritized by employee type

Hospital 4 43 increased access

Hospital 5 40 increased access

Hospital 8 34 increased access

Hospital 9 27 increased access

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Single Arm Studies Author Population (N) Baseline %/

Change %Intervention(s)

Ribner, et al. All non-MD employees (9,200) 43.0+23.5

feedback, incentive, manager support, consent/ declination form

Polgreen, et al. (2008)

All employees (22 hospitals) 54+11.6

declination/ consent form

Bertin, et al. All employees (20,170) 38+17

feedback, manager support, Intranet form

Kuntz, et al. All employees (5,467) 41+10

education, increased access, peer vaccination, feedback, free, vaccine champion

Nicholson, et al. All employees (3,200) 45+20

education, e-mail, increased access, declination/consent form, peer vaccination

Shah, et al. All employees (112) 41+26

education, vaccine available to parents, increased access

Nace, et al. All employees (236) 54.0+32.0

education, feedback, manager support, declination/consent form

CDC All employees (25,000) 53.6+23.5

education, increased access, free, peer vaccination, vaccine champion

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Results

• Multiple Arm Studies:– Education necessary but not sufficient– Increased access associated with higher

vaccination rates, but not on its own– Incentives and declination/consent forms may also

have impact

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Results

• Single Arm Studies:– Education works best with other interventions– Incentives associated with increases– Easier access has impact as well

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Results

• Combination of interventions may prove successful

• Education and easier access seem necessary foundation

• Also need:– Declination/consent forms– Incentives

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Conclusion

• Vaccine is best protection against the flu• Short of mandating vaccines, what tools are

available to health care organizations?– Intranet-based intervention– Combination of interventions may be most

successful• Free vaccine that is easily accessible• Education campaign• Incentives• Online declination/consent form

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Policy Implications and Recommendations

• Changes in institutional policies• The Joint Commission• State governments• Other incentives– U.S.News & World Report– Most Wired Hospitals

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Further Study

• Further testing of Intranet intervention hypothesis

• Replication of multiple arm, pre-post intervention study by Zimmerman

• Larger systematic review to include interventions from abroad

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Thank You

• Dr. Pauline Rosenau• Dr. L. Kay Bartholomew• Dr. Kay Dunn • Dr. Beatrice Selwyn• Dr. Margaret Price • David Koontz

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Thank You