Improving Pneumococcal Immunization of Adults With Immunocompromising Conditions in Ambulatory Specialty Practices

By Andrzej Kulczycki, PhD, School of Public Health, University of Alabama at Birmingham (UAB), Birmingham, Alabama

Project Description 

The overall project goal is to affect changes to improve pneumococcal vaccination uptake and patient care in three ambulatory specialty practices at a tertiary university medical center.

The primary target group includes healthcare professionals working to immunize adults with immunocompromising conditions (IC) at three clinics (multiple myeloma, rheumatology and renal transplant) and more widely in the university health system.  A second target group comprises IC patients in these clinics.

The three planned interventions are to:

  • Develop and implement CME activities to help healthcare professionals be more proactive in providing pneumococcal vaccination to IC patients
  • Adapt a non-physician-led model to multiple myeloma and rheumatology clinics
  • Develop a patient-centric model through innovative gamified education for use by patients in renal post-transplant and rheumatology clinics

The primary educational products include a CME activity and a patient education game.

Impact of COVID-19

Our delivery strategies have been re-thought due to pandemic restrictions. The CME activity will be delivered as an asynchronous online webinar using teleconferencing technology. Planned on-site clinic presentations and a potential Grand-Rounds meeting were canceled due to COVID-19 restrictions. The patient education game may now be delivered using patients’ smartphones in clinic waiting rooms, should hygiene concerns associated with computer tablet use prove insurmountable. A learning collaborative planned to assist with introducing clinic system changes has been postponed and may need to be shelved for comparable reasons.

The intended outcomes include:

  • Changes in pneumococcal vaccination numbers and rates in each clinic and overall (pre- and post-intervention)
  • Changes in patient knowledge and engagement levels at two clinics where the patient gamification is to be implemented

Accomplishments

  • Impact on participants/learners
    • We began the project in December 2019. In the three months before the pandemic hit, we:
      • Built our partnership across the clinic sites that also included the HIV and BMT (bone marrow transplant) clinics, so as to allow for expanded pneumococcal vaccination activities on campus.
      • Conducted a needs assessment at all five clinics. This was mostly completed but could not be finalized prior to the lockdown and the university’s shift to a limited business model.
  • Impact related to pneumococcal vaccination numbers/rates
    • This also cannot yet be demonstrated due to pandemic postponement. However, at project baseline (end 2020), pneumococcal vaccination rates at all three main project clinics were low. Although the data are incomplete, approximately 20–30% of patients had been vaccinated and rates are only high (>90%) at the two model clinics (HIV and BMT). The suspension of normal business and clinic activities has limited our impact to date.
  • Other data related to the project
    • We have built awareness of the need for institutional changes to implement strategies to improve vaccination rates. We have identified topics and priorities for CME and prepared content material. This will be launched soon, as the university health system gradually resumes more regular routines and eases other delays after mass COVID-19 vaccination activities.

The project remains at too early a stage to achieve changes in healthcare delivery practices, and vaccinations have not been prioritized during the pandemic. However, we anticipate registering positive changes following intervention implementation.

The university electronic medical record has built-in management modules for monitoring patient vaccination, but this is not user-friendly and our project resources are too small to enact change in this area. However, we are hopeful we can assist clinic staff to help navigate this system.

Dissemination

The project was stalled at an early stage, but dissemination activities such as conference posters are anticipated after resuming project activities. At least one planned journal manuscript will discuss and publicize the comprehensive CME development process, given its potential value to others. We are now resuming our CME development work and anticipate being able to launch this shortly.

Pandemic Challenges

The profound challenges posed by the pandemic manifested in mid-March 2020, with normal clinic activities suspended and routine patient management heavily disrupted to this day. Even with a relative lull in the pandemic in early summer, clinic staff remained re-assigned to COVID-19-related duties, precluding resumption of project work. The HIV clinic would later move, and its staff also was assigned to help set up COVID clinics. The UAB health system continues to operate around the COVID-19 pandemic. We hope to resume activities shortly as COVID vaccination gains pace, but clinics will face many competing priorities.

Other challenges included start-up delays, staff turnover and data accessibility problems. Late project execution resulted from lengthy institutional reviews and a protracted IRB process. Afterward, the university lost its main infectious diseases physician liaison with the health system transplant units, who was committed to facilitating further grant contacts. Also, we encountered unexpected difficulty accessing data as the health informatics unit now charges for clinic-specific data that our limited budget does not allow for. We will track pneumococcal vaccinations administered using billing data, though this is not possible at the sub-clinic level.

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