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Clinical Infection & Immunity

Original Article

Volume 9, Number 1, March 2024, pages 11-15

Improving Influenza Vaccination Coverage: A Quality Improvement Project in Internal Medicine Clinic

Influenza is a preventable communicable disease associated with significant morbidity and mortality, and infants and elderly are the most vulnerable population [1]. The influenza vaccine is recommended for all individuals above the age of 6 months who do not have a contraindication per the Advisory Committee for Immunization Practices (ACIP) [2]. Improved utilization of various settings including primary care clinics can improve influenza vaccination coverage and prevent morbidity and mortality, and health-related costs. Primary care clinics are convenient places to get vaccines including influenza vaccine. Educating the staff and providers on addressing patients’ concern and effective communication strategies can have a significant impact on vaccines’ coverage.

The number of patients visiting the internal medicine (IM) clinic declined in the year 2020 and 2021, along with the administration of influenza vaccine during the flu season. The patient number started to pick up in early 2022. We had observed (a subjective observation) that there was a general hesitance regarding vaccination, and in particular towards influenza vaccine and questioning its efficacy amid the buzz around newly developed coronavirus disease (COVID) vaccines. We decided to initiate a quality improvement (QI) project through provider education and reminders in the fall and early winter of 2022, to improve influenza vaccine coverage. The details and findings of our study are reported in the sections below.

The IM primary care clinic provides care to adults, aged 18 years or above. It serves a relatively underserved area and the health literacy is considered to be low. The providers in the IM clinic routinely offer the patients influenza vaccination during the flu season. The vaccine is usually available early to mid-September until late April, but the vaccination rates are higher from October to December.

The QI study was conducted over 12 weeks, from October to December 2022, at the IM residents’ run primary care clinic. The intervention (education) was implemented every alternate week (intervention group) and was compared to the weeks on which the education was not done (comparison group), i.e., 6 weeks each. The providers in the intervention group were educated prior to starting the study, in a group setting. A brief education was done again at the beginning of the week in the intervention group. They were given handouts of the education material as well and were advised to counsel all patients on influenza vaccine if possible, and document their interaction in the electronic record system as they normally would. Copies of the education material were placed at the providers’ workstation on the weeks of intervention. Providers were handed a copy of a simple three questions questionnaire along with the face-sheet before seeing a patient (face-sheet has the demographic information of the patient presenting to the clinic) by the nurse (Supplementary Material 1, www.ciijournal.org).

On average, 3 - 5 providers were present in the clinic each day. The providers encircled the options of “yes” or “no” for the initial two questions on a three questions questionnaire, and free texted the answer to the third question. They proceeded to the second question only if the answer to first question was “no”, and proceeded to question three if the answer to second question was “no” (Fig. 1). 1) Did you receive flu vaccine this year? 2) Are you interested in getting influenza vaccine today? 3) Reason the vaccine was declined.

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Figure 1. Schematic diagram of the intervention through providers’ education.

The primary intended outcome was improving the rate of influenza vaccine being offered to the patients seen in the clinic and the secondary outcome was increasing the influenza vaccine acceptance rate, i.e., the vaccine being administered that day. When a provider initiated a discussion with a patient regarding the influenza vaccine, it was considered as “vaccine offered”, regardless of vaccine being accepted or declined. To calculate the vaccine’s acceptance rate, patients who had already received the influenza vaccine were excluded, as the providers by default did not go further from this point to educate and counsel the patient on the influenza vaccine.

IRB approval was obtained prior to the study. The study was conducted in compliance with the ethical standards of the responsible institution on human subjects as well as with the Helsinki Declaration.

A total of 726 patients were seen by the providers in the IM clinic during the study period, 381 patients were seen by the providers in the intervention group, and 345 patients were seen by the providers in the comparison group. In the intervention group, 33.6% (n = 128) patients were offered the influenza vaccine compared to 17.1% (n = 59) patients in the comparison group by the provides (Fig. 2). In the intervention group, 13.65% (n = 52) patients agreed to receive the influenza vaccine and it was administered during the visit, compared to 8.70% (n = 30) in the comparison group. Providers who received education were more likely to offer vaccine (discuss with the patients) (χ² (1, N = 726) = 25.76, P < 0.00001 without Yates correction, and χ² (1, N = 726) = 24.90, P < 0.00001 with Yates correction) (Table 1). There was no difference in the proportion of patients who ultimately agreed to receive the vaccine, as no statistically significant difference was noticed on the percentage of patients accepting the vaccine (χ² (1, N = 187) = 1.714, P = 0.1905 without Yates correction, and χ² (1, N = 187) = 1.324, P = 0.124 with Yates correction) (Table 2).

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Figure 2. Percentage of patients who were offered the influenza vaccine (blue bars) and patients who accepted the influenza vaccine (orange bars) in both the groups.

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Table 1. Chi-Square Test of Independence to Examine the Relation Between Providers’ Education and Vaccine Offering

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Table 2. Chi-Square Test of Independence to Examine the Relation Between Providers’ Education and Vaccine Being Accepted (Received)

We noticed that only one-third of the patients were offered the influenza vaccine when we first analyzed the data, which seemed surprisingly low for a primary clinic. It was observed that the providers were less likely to offer influenza vaccine if the patient’s primary reason for a visit was “an acute complaint” or “a pre-operative evaluation”. Ninety-six patient visits in the intervention group and 102 patients in the comparison group were either an acute visit or a pre-operative evaluation. Two (2.1%) patients in the intervention group and five (4.9%) patients in the comparison were offered the vaccine. In general, the providers were more likely to initiate a discussion on vaccination at visits for “preventive care”, “general physical exam’, or “wellness visits”. These findings suggest that the providers might be less likely to discuss vaccination if the patient had an acute problem on the day or if they were scheduled for a procedure, but isolating that data is relatively difficult.

The providers in the intervention group documented the reason due to which the patients declined influenza vaccine but this was rarely documented in the comparison group, as they simply reported that the vaccine was declined. Although improved documentation was not on our objectives list, it was a definitely welcomed outcome as a result of providers education. The most common reasons for declining influenza vaccine in decreasing order of frequency were: not interested (either did not believe in its efficacy or felt it was unnecessary as they were healthy), adverse reaction (either the patient or someone they knew had a reaction as a result of influenza vaccine) and being scared of needles in general.

Influenza activity in 2022 season started earlier compared to the previous seasons, and influenza-associated hospitalizations among children were higher [3]. The surveillance data on influenza reported by Center of Disease Control (CDC) from October 2, 2022 to July 29, 2023 show that more than 3.7 million specimens were tested for influenza infection at clinical laboratories and 356,632 (9.5%) tested positive, of which 97.5% were positive for influenza type A and 2.5% were positive for influenza type B [4]. Flu vaccine coverage among adults ≥ 18 years was 0.8% lower at 49.4% in 2021 - 2022 season, compared to 50.2% in 2020 - 2021 season [5]. Compared to the pre-COVID-19 pandemic seasons, influenza vaccine coverage has been lower in the United States (US), especially in children, pregnant women and in rural areas [6]. Providers are advised to offer vaccines during routine health care visits and hospitalizations to avoid missed opportunities for vaccination, and flu vaccine and COVID-19 vaccines can be administered simultaneously [3]. The effectiveness of the 2022 - 2023 influenza vaccine was found to be 54% among adults aged < 65 years for preventing medically attended influenza A infection, and 71% among children and adolescents aged < 18 years for preventing symptomatic influenza A illness, in two concurrent studies in Wisconsin [7].

The influenza vaccine has multiple evidence-based benefits despite the reported low intake [1]. There are general misconceptions regarding influenza vaccine, especially, regarding its efficacy and potential side effects. There is an assumption of the side effects even before the side effects are known [8], hence individuals who are not well-informed might not take the vaccine out of fear [1]. When the term “influenza vaccine” is used instead of “flu shot”, an individual is more likely to be vaccinated [9, 10]. Two of the biggest factors that determine if an individual will take the vaccine are age and race. Older adults are more likely to get influenza vaccine as there is a higher chance of developing complications, and adults ≥ 65 years old have a higher vaccination rate compared to 18 - 64 years old. Disparities exist in vaccination rates among non-Hispanic whites and individuals from African-American or Hispanic background [1]. The CDC reports a list of important misconceptions regarding the influenza vaccine, the common reasons being: “the flu isn’t that serious”, “I don’t need to get vaccinated against the flu”, “My job doesn’t put me at risk for getting the flu”, “I got the flu vaccine last year so I don’t need to get vaccinated this year”, “The flu vaccine doesn’t work”, “The flu vaccine can give me the flu”, and “The vaccine is not safe” [11]. Patient education is often advocated as they go to solution to overcome these barriers and improve vaccination rates, which can be provided in many ways. A discussion held by a health care physician with the patient can have a profound effect on increasing vaccine acceptance and the patient making an informed decision. Hence, primary care clinics can play an important role in improving influenza (or any other vaccine) vaccination rates as the conversation is centered around the patient in these motivational conversations, and it also leads to a stronger patient-provider relationship [12]. The intervention tool, i.e., providers’ education and reminders, is a simple tool that has a significant effect on improving the discussion between the providers and patients. It did not have an impact on improving the percentage of vaccine being accepted, suggesting that there remain significant barriers in this regard. We believe that some of these barriers and associated factors as mentioned above might be specific to the influenza vaccine. Further work is needed to explore reasons behind these barriers and find ways to overcome them. The improved effect of providers education, i.e., patient centered conversation can be sustained by continuing weekly providers’ education and we have continued to observe the positive response in our clinic.

Our study had certain limitations. Logistic problems like the nurse forgetting to attach the questionnaire to the face-sheet before each visit or the provider forgetting to offer the vaccine are possible but the likelihood of that is small to the best of our knowledge. The providers’ being unable to document their discussion with the patient is also a possibility due to limited time. Educating a different set of providers every other week could be challenging if this study was to be conducted at another site. Our facility being a teaching clinic, it is relatively easier to incorporate weekly providers education. The misconceptions around the COVID-19 infection and vaccination against it, might have had a negative influence on getting the influenza vaccine. It is important to report that there was no interruption of supply of the influenza vaccine or unavailability of the nurses administrating the vaccine during the study.

Primary care clinics are important avenues to improve vaccine coverage as it provides a safe environment to conduct a patient centered conversation. A simple intervention like providers’ education and reminders at the beginning of influenza season can significantly improve the frequency of discussions around vaccination against influenza and its pros and cons. This in turn can improve vaccine coverage, and prevent influenza-related morbidity and mortality.

Suppl 1. Education material/questionnaire.

Acknowledgments

None to declare.

Financial Disclosure

None to declare.

Conflict of Interest

None to declare.

Informed Consent

IRB approval was obtained prior to the study and approval certificate was available upon editor’s request.

Author Contributions

Yasir Ahmed, MD, as primary author and corresponding author, contributed to conception of the study, design and location, was responsible for data collection and conducted analysis/results and discussion, conducted providers’ education, drafted the initial and final draft and did final review prior to submission. Varun Rajagopalan, MD, contributed to introduction and case description. Pooneh Farhangi, MD, contributed to discussion, review and editing. Nadia Debick contributed to data collection and discussion. Zainab Imtiaz, MD, contributed to data collection and discussion. Daniel Chin, MD, supervised the entire process, reviewed literature search, referencing, and approval for publishing after review and editing.

Data Availability

The authors declare that data supporting the findings of this study are available within the article.

1. Baltes M, Pronovost E, Kanuch S, Caron A. Improving influenza vaccination rates in an underserved primary care clinic using a simple educational tool. Qual Manag Health Care. 2022;31(2):80-84.
   doi pubmed
2. Grohskopf LA, Alyanak E, Broder KR, Walter EB, Fry AM, Jernigan DB. Prevention and control of seasonal influenza with vaccines: recommendations of the advisory committee on immunization practices - United States, 2019-20 Influenza Season. MMWR Recomm Rep. 2019;68(3):1-21.
   doi pubmed pmc
3. Grohskopf LA, Blanton LH, Ferdinands JM, Chung JR, Broder KR, Talbot HK, Morgan RL, et al. Prevention and control of seasonal influenza with vaccines: recommendations of the advisory committee on immunization practices - United States, 2022-23 Influenza Season. MMWR Recomm Rep. 2022;71(1):1-28.
   doi pubmed pmc
4. Influenza Activity in the United States during the 2022-23 Season and Composition of the 2023-24 Influenza Vaccine. https://www.cdc.gov/flu/spotlights/2023-2024/22-23-summary-technical-report.htm.
5. Flu Vaccination Coverage, United States, 2021-22 Influenza Season. https://www.cdc.gov/flu/fluvaxview/coverage-2022estimates.htm#ref1.
6. CDC. Influenza (flu): weekly flu vaccination dashboard. Atlanta, GA: US Department of Health and Human Services, CDC; 2023. Accessed February 14, 2023. https://www.cdc.gov/flu/fluvaxview/dashboard/vaccination-dashboard.html.
7. McLean HQ, Petrie JG, Hanson KE, Meece JK, Rolfes MA, Sylvester GC, Neumann G, et al. Interim estimates of 2022-23 seasonal influenza vaccine effectiveness - Wisconsin, October 2022-February 2023. MMWR Morb Mortal Wkly Rep. 2023;72(8):201-205.
   doi pubmed pmc
8. Yeung MP, Lam FL, Coker R. Factors associated with the uptake of seasonal influenza vaccination in adults: a systematic review. J Public Health (Oxf). 2016;38(4):746-753.
   doi pubmed
9. Nowak GJ, Cacciatore MA, Len-Rios ME. Understanding and increasing influenza vaccination acceptance: insights from a 2016 National Survey of U.S. Adults. Int J Environ Res Public Health. 2018;15(4):711.
   doi pubmed pmc
10. Cummings CL, Kong WY. "Influenza" versus "Flu": Do different medical terms affect vaccination intention? J Health Commun. 2019;24(4):456-460.
    doi pubmed
11. Paulus M. The multidimensional nature of early prosocial behavior: a motivational perspective. Curr Opin Psychol. 2018;20:111-116.
    doi pubmed
12. Gagneur A, Gosselin V, Dube E. Motivational interviewing: A promising tool to address vaccine hesitancy. Vaccine. 2018;36(44):6553-6555.
    doi pubmed

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Clinical Infection and Immunity is published by Elmer Press Inc.