Infectious Diseases

Improving Influenza and Pneumonia Vaccination Among Veterans

February 4, 2014

Overview

Investigators from SCI-QUERI examined vaccination rates for Veterans with spinal cord injury between 1996 and 1998 and noted that they were low across all three years (13%, 25%, 26%). Subsequently, SCI-QUERI developed and implemented a multi-pronged intervention in collaboration with VA SCI/D Services. As of July 2008, vaccination rates had increased to 75.6% for influenza and 90.5% for pneumonia; vaccination rates for influenza rose again - to 77% by July 2010 (no data available for pneumonia rates for 2010).

Research and Clinical Collaboration

With the recent H1N1 (Swine) flu pandemic and the resulting world-wide attention directed at containment and vaccination, it is hard to remember that just twenty years ago vaccinations for flu and pneumonia were not common practice. In the early 1990's VA HSR&D investigators found that:

• All people, not just the elderly or at-risk groups, should consider annual vaccination;
• Vaccination is cost-effective;
• All VA patients and employees should be considered for vaccination; and
• Vaccination of healthy working adults decreases absenteeism from work due to flu.

Based on this research evidence, investigators recommended immunization programs that included:

• Instructions for administration and documentation of the influenza vaccine be posted in exam rooms;
• Education for patients, providers, and staff that emphasizes the seriousness of influenza, as well as the effectiveness and safety of the vaccine; and
• The program's success should be measured and evaluated.

To further disseminate the findings, an issue of VA Practice Matters–a VA/HSR&D publication devoted to single healthcare topics—was published summarizing the evidence about influenza immunization and was broadly distributed throughout VA. The issue advised that to achieve higher immunization rates, providers must implement organized programs that automated offering and administering vaccinations. Program components suggested for inclusion were: standing orders, walk-in clinics, pre-printed information/documentation forms, and an annual educational/publicity mailing to patients.

Since that report came out in 1996, VA managers, clinicians, and researchers have made enormous strides in the rates of influenza and pneumonia vaccination among VA patients and healthcare workers. However, influenza and pneumonia remain one of the leading causes of death in the United States, despite the availability of highly effective vaccines. Thus, before every flu and pneumonia, VA disseminates vaccination promotional materials and reminders.

Expanding Vaccinations to Vulnerable Veterans

The VA healthcare system serves more than 25,000 persons with spinal cord injury and/or disorder (SCI&D), making it the largest integrated healthcare system in the world for SCI/D. Researchers had found that persons with spinal cord injury had a 37% higher likelihood of death from influenza or pneumonia than the general public. Investigators from VA/HSR&D's Spinal Cord Injury Quality Enhancement Research Initiative (SCI-QUERI) examined vaccination rates for Veterans with SCI between 1996 and 1998, and noted that they were low across all three years (13%, 25%, 26%).

Subsequently, SCI-QUERI developed and implemented a multi-pronged intervention in collaboration with VA SCI/D Services that included:

1. patient reminder letters and education,
2. provider reminders and posters,
3. computerized clinical reminders, and
4. nurse standing orders to support vaccination efforts at four VA SCI Centers. The following year, the program was expanded to all 23 SCI Centers and included pneumococcal vaccinations. By the end of the study (July 2005), rates for influenza and pneumococcal vacations were 66.5% and 83.4%, respectively.¹ As of July 2008, vaccination rates had increased to 75.6% for influenza and 90.5% for pneumonia, and vaccination rates for influenza rose again–to 77% by July 2010 (no data available for pneumonia rates for 2010).

Research at Work:

Working to making a difference in the lives of Veterans, HSR&D investigators have contributed important research findings toward increasing influenza and pneumonia vaccination rates.

• A study assessed the impact of influenza vaccination on the risk of hospitalization for ischemic heart disease and stroke among two large cohorts of community-dwelling elderly persons for the 1998-99 and 1999-00 influenza seasons. Results showed that influenza vaccination of the elderly was associated with lower rates of hospitalizations for cardiac disease, stroke, pneumonia, and influenza during the flu season, and was associated with fewer deaths from all causes.²
• VA has been shown to be a leader in preventative care. An HSR&D study used VA and Medicare data to examine self-reported use of influenza vaccination, pneumococcal vaccination, serum cholesterol screening, and serum prostate-specific antigen measurement (PSA for prostate cancer screening) among male Veterans 65 years and older. Findings showed that receiving all or some healthcare through VA was associated with increased use of preventive care. ³
• This study analyzed the effectiveness of influenza vaccination among community-dwelling elderly (65 years and older) members of U.S. health maintenance organizations (HMOs) during 10 flu seasons. Results showed that over 10 flu seasons, influenza vaccination was associated with substantial reductions in hospitalizations for pneumonia or influenza, and decreased mortality. Vaccination was associated with a 27% reduction in the risk of hospitalization for pneumonia or influenza and a 48% reduction in the risk of death. ⁴

References

1. Weaver FM, Smith B, LaVela S, et al. Interventions to increase influenza vaccination rates in Veterans with spinal cord injuries and disorders. Journal of Spinal Cord Medicine 2007;30(1):10-9.
2. Nichol K, Nordin J, Mullooly J, et al. Association of influenza vaccination with lower rates of hospitalization for cardiac disease and stroke among the elderly. The New England Journal of Medicine 2003;348:1322.
3. Keyhani S, Ross J, Hebert P, et al. Use of preventive care by Veterans receiving care through the Veterans Health Administration, Medicare FFS, and Medicare HMO Plans. American Journal of Public Health December 2007;97(12):2179-85.
4. Nichol K, Nordin J, Nelson D, et al. Effectiveness of influenza vaccine in the community-dwelling elderly. The New England Journal of Medicine 2007;357(14):1373-81.

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