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Offering the Influenza Vaccine in a Pediatric Hand Surgery Clinic Increases Vaccination Rates

Published:March 15, 2018DOI:https://doi.org/10.1016/j.jhsa.2018.01.017

      Purpose

      The purpose of this study was to evaluate the utility of providing immediate access to the influenza vaccination for patients seen in a pediatric hand surgery clinic. Our hypothesis was that providing access would increase the rate of vaccination.

      Methods

      This pilot study was a randomized, controlled, prospective clinical trial that included all patients seen by a single surgeon, on a single day each week, in a hospital-based pediatric hand surgery practice clinic from October 18, 2016, to March 14, 2017. All patients between 6 months and 18 years of age seen during their initial visit during the study period were included. All patients were questioned on their vaccine status. For the intervention group, the influenza vaccine was offered. If requested, after providing educational materials, written consent from the parent or guardian was obtained. The vaccine was given by the registered nurse ordinarily assigned to the clinic. Demographic information and vaccine status for both groups at the end of clinic, including the date of receiving the vaccine, were recorded.

      Results

      Similar proportions of patients in each group had received the vaccine prior to being seen in the clinic. In the intervention group, 80 children (67%) had received the vaccine by the end of clinic, compared with 29 (25%) in the control group. Patients who were offered the vaccine had a statistically significant higher vaccination rate. Of the 80 patients in the intervention group who received the vaccine, 47 (59%) received it in the hand clinic.

      Conclusions

      This project demonstrated that offering the influenza vaccine in a nontraditional setting, an outpatient hand surgery clinic, increased the proportion of patients receiving the vaccine.

      Type of study/level of evidence

      Therapeutic I.

      Key words

      The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics recommend yearly influenza vaccination for all children 6 months of age and older. Administration of the vaccine early in the influenza season is recommended for optimal protection.

      Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices—United States, 2013–2014. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6207a1.htm. Accessed May 26, 2015.

      Committee on Infectious Diseases, American Academy of Pediatrics
      Recommendations for prevention and control of influenza in children, 2014–2015.
      • Grohskopf L.A.
      • Sokolow L.Z.
      • Broder K.R.
      • et al.
      Prevention and control of seasonal influenza with vaccines.
      Committee on Infectious Dseases
      Recommendations for Prevention and Control of Influenza in Children, 2016–2017.
      The vaccination rate for children aged 6 months to 17 years was estimated by the CDC to be 59% for the 2015 to 2016 flu season. Younger children have a higher rate of vaccination than older children.
      • Santibanez T.A.
      • Grohskopf L.A.
      • Zhai Y.
      • Kahn K.E.
      Complete influenza vaccination trends for children six to twenty-three months.
      Most vaccines are administered at a health care facility. A doctor’s office is the most common place for children to receive the influenza vaccine.
      • Lu P.J.
      • Santibanez T.A.
      • Williams W.W.
      • et al.
      Surveillance of influenza vaccination coverage—United States, 2007–8 through 2011–12 influenza seasons.
      The low number of visits to primary health care providers by healthy school-age children accounts for much of their low vaccination rate.
      Committee on Infectious Dseases
      Recommendations for Prevention and Control of Influenza in Children, 2016–2017.
      • Nowalk M.P.
      • Lin C.J.
      • Hannibal K.
      • et al.
      Increasing childhood influenza vaccination: a cluster randomized trial.
      Outpatient clinics that treat a large number of injured but otherwise healthy children, such as hand surgery, plastic surgery, and orthopedic surgery, provide an opportunity to provide vaccinations to children who ordinarily would not visit a health care provider during the influenza season.
      The purpose of this study was to evaluate the utility of providing immediate access to the influenza vaccination for patients seen in a pediatric hand surgery clinic. Our hypothesis was that providing access would increase the rate of vaccination.

      Materials and Methods

      This study was a block randomized, controlled, prospective clinical trial. Institutional review board permission was obtained. The study included all patients seen by a single surgeon (R.L.H.), in a hospital-based pediatric hand surgery clinic, between October 18, 2016, and March 14, 2017. It was limited to the same, single day each week when patients were seen in the morning and the afternoon. All patients seen for their initial visit during the study period were included. Exclusion criteria included patients seen for follow-up visits if they were already enrolled in the study, and patients aged younger than 6 months or older than 18 years. Clinics were randomized by block randomization in sets of 10 to receive the intervention in either the morning or the afternoon. The patients were not randomized; the clinic time (morning or afternoon) was randomized.
      Information was recorded on a questionnaire by the hand surgeon. For each group, the information recorded was age, contraindication to vaccine, vaccination status for 2016 to 2017, and date of receiving the vaccine. No other information or discussion of the vaccine was provided to the control group. The influenza vaccine was offered to the intervention group. After providing educational materials and obtaining written consent from the parent or guardian, the vaccine was given by the registered nurse (RN) ordinarily assigned to the clinic to those children who agreed to receive it. The routine protocols of the institution were followed for influenza vaccination.
      The additional service of providing the vaccine was done during regular clinic time, with a normal scheduling format, and the usual clinic staffing level. The number of clinic workers and the usually allotted time per patient encounter were not altered. The vaccine was provided by the hospital pharmacy and kept in the clinic in an iced cooler to maintain refrigerator temperature. Unused vaccine was returned to the pharmacy at the end of the clinic. All patients were included in the primary analysis.
      Summary statistics were used for the demographic information and rates by age. The primary outcome measure, vaccination status at the end of the visit, was evaluated with the chi-square test to compare proportions. Age was compared with the Student t test. Significance was set at P less than .05.
      Sample size determination was based on a baseline vaccination rate of 50%. The expected rate in the experimental group was 70%. Setting alpha at 0.05, and beta at 0.2 for a 2-tailed test, the sample size needed for the dichotomous primary response rate for independent samples was 59 per group.

      Results

      The intervention group contained 120 patients, and 115 patients were in the control group. The mean age was 9.9 years (range, 8 months to 17 years). There was no difference in mean age between the intervention and the control groups (intervention, 10.0 years; control, 9.8 years).
      In the intervention group, 27% of the patients presented to the clinic already vaccinated, compared with 25% in the control group. Thirty-nine percent of the patients in the intervention group were vaccinated during their visit. The total proportion in the intervention group that was vaccinated at the end of the visit was 67%. The difference in the proportion vaccinated between the invention and the control group was statistically significant (Table 1).
      Table 1Results by Group
      ControlIntervention
      Patients (n)115120
      Age, y (mean, range)9.8 (0.66–17)10.0 (0.75–17)
      Already received29 (25%)33 (27%)
      Declined40 (33%)
      Received in clinic47 (39%)
      Vaccinated (%)25%
      Indicates statistical significance (P < .05).
      67%
      Indicates statistical significance (P < .05).
      P < .001
      Indicates statistical significance (P < .05).
      Table 2 compares the intervention group by school-age status. School-age children were less likely to be vaccinated prior to their clinic visit than younger children. School-age children also had lower vaccination rates after the clinic visit than preschool-age children. A larger percentage of the school-age children (59%) were vaccinated in the clinic than the preschool-age children (29%).
      Table 2Results in Intervention Group by School Age
      Vaccinated Prior to ClinicVaccinated in ClinicNot Vaccinated at

      End of Clinic
      Total Vaccinated at

      End of Clinic
      Preschool (6 mo to 4 y)13 (54%)7 (29%)4 (17%)20 (83%)
      School (517 y)21 (22%)40 (49%)35 (37%)61 (63%)

      Discussion

      This project demonstrated that offering the influenza vaccine in a nontraditional setting, an outpatient hand surgery clinic, increased the proportion of patients receiving the vaccine. The greatest utility was in the older age groups, who may have not otherwise seen a medical provider during the influenza season. Consideration should be given to expanding the access to the influenza vaccine to hand surgery and other surgical clinics in order to capture children who might otherwise not receive influenza immunization. The CDC have developed a step-by-step process for ordering and providing influenza vaccine in the outpatient office setting. The link is found at: https://www.cdc.gov/flu/professionals/vaccination/vax_clinic.htm.
      Unlike adults, most children receive their influenza vaccine at a health care visit, typically at their primary care provider’s office, and less commonly, at a medical subspecialty office. Of those vaccinated, about 65% receive the vaccine at the doctor’s office and about 18% at a clinic/health center. Less than 5% receive the vaccine at emergency departments, pharmacies, or schools.
      • Santibanez T.A.
      • Vogt T.M.
      • Zhai Y.
      • McIntyre A.F.
      Place of influenza vaccination among children—United States, 2010–11 through 2013–14 influenza seasons.
      Many children are seen by their primary care provider once annually in the late spring and/or summer months when they are out of school and are in need of a complete physical examination either for sports participation or before the start of the next school year. However, influenza vaccine is routinely not available until late August and sometimes September. Thus, there are a large number of otherwise healthy children who likely would not present to a provider who routinely provides influenza vaccine during the time frame in which the vaccine is typically provided (August/September through March/April). This low number of visits to a health care provider by healthy school-age children accounts for much of their low vaccination rate.
      • Nowalk M.P.
      • Lin C.J.
      • Hannibal K.
      • et al.
      Increasing childhood influenza vaccination: a cluster randomized trial.
      The patients in our study followed a similar pattern. In both the control and the intervention groups, older children were less likely to be vaccinated than younger children at study entry.
      National recommendations to improve influenza vaccination rates include offering the vaccine at every visit to all patients who see a health care provider, and expanding access to nontraditional settings.
      • Srivastav A.
      • Zhai Y.
      • Santibanez T.A.
      • Kahn K.E.
      • Smith P.J.
      • Singleton J.A.
      Influenza vaccination coverage of Vaccine for Children (VFC) –entitled versus privately insured children, United States, 2011–2013.
      • Santibanez T.A.
      • Lu P.J.
      • O'Halloran A.
      • Meghani A.
      • Grabowsky M.
      • Singleton J.A.
      Trends in childhood influenza vaccination coverage—U.S., 2004–2012.
      • Jacob V.
      • Chattopadhyay S.K.
      • Hopkins D.P.
      • et al.
      Increasing coverage of appropriate vaccinations: a community guide systematic economic review.
      • Murphy P.A.
      • Frazee S.G.
      • Cantlin J.P.
      • Cohen E.
      • Rosan J.R.
      • Harshburger D.E.
      Pharmacy provision of influenza vaccinations in medically underserved communities.
      In our children’s hospital and clinic settings, the vaccine had not been offered previously in surgical clinics. Clinics that offer the vaccine include Primary Care Pediatrics, Allergy, Hematology/Oncology, Endocrinology, Infectious Diseases, Gastrointestinal, and Pulmonary.
      Several key factors serve to increase influenza vaccination rates, including convenient vaccination services (offered at the appointment) and enhanced office systems to facilitate immunization (eg, nurse buy-in, standing order sets).
      • Nowalk M.P.
      • Lin C.J.
      • Hannibal K.
      • et al.
      Increasing childhood influenza vaccination: a cluster randomized trial.
      • Jacob V.
      • Chattopadhyay S.K.
      • Hopkins D.P.
      • et al.
      Increasing coverage of appropriate vaccinations: a community guide systematic economic review.
      Barriers to children receiving influenza vaccine include lack of convenience to receive the vaccine (not offered at the appointment) and parental misperception regarding the risks of developing influenza infection and the potential severe outcomes of influenza disease.
      • Schmid P.
      • Rauber D.
      • Betsch C.
      • Lidolt G.
      • Denker M.L.
      Barriers of influenza vaccination intention and behavior - a systematic review of influenza vaccine hesitancy, 2005–2016.
      Offering the vaccine to healthy children who may not be seen by another provider during influenza season improves convenience for the parents. Patients who were not vaccinated at the beginning of the clinic visit tended to be older than the patients who had already received the vaccine; thus, a higher proportion of children who received the vaccine in the clinic were older. Most of these patients were otherwise healthy and were being treated for injuries. This distribution is consistent with other studies.
      • Santibanez T.A.
      • Grohskopf L.A.
      • Zhai Y.
      • Kahn K.E.
      Complete influenza vaccination trends for children six to twenty-three months.
      Whereas intervention programs have been shown to increase influenza vaccination rates, to our knowledge, this is the first study to show increased influenza immunization rates in healthy children seen in an outpatient hand clinic at a children’s hospital.
      The clinic studied is staffed by 1 RN, along with shared care assistants and cast technicians. The amount of time spent by the RN was not recorded, but there was no change in the number of patients seen per clinic or in the clinic flow. Our RN does not routinely accompany the surgeon into the examination room. The vaccine education and administration was often performed while the patient was waiting for radiographs or casting, or while the RN was performing preoperative teaching. There was no additional cost to the hospital for staffing of the clinic. There was no direct cost for the vaccine to the hospital. For patients with commercial coverage, the cost of the vaccine was billed to the insurance company. For patients on Medicaid, the cost of the vaccine was covered by the federally sponsored Vaccines for Children program.
      Although we did not ask, some parents offered their reason for not wanting their child to receive the vaccine. Reasons for the parent declining vaccination were varied, with the most common reason being the belief that the vaccine is not necessary. In our study, the families were not pressured nor were additional educational measures taken. Because the vaccine was only being offered to the patients, some families wanted to wait and bring all their children to the primary care office at the same time. Further studies need to be done on the reasons for refusal and whether simple educational measures can improve acceptance.
      This project demonstrated that offering the influenza vaccine in a nontraditional setting, an outpatient hand surgery clinic, increased the proportion of patients receiving the vaccine. The greatest utility was in the older age groups, who may have not otherwise seen a medical provider during the influenza season. Consideration should be given to expanding the access to the influenza vaccine to hand surgery and other surgical clinics in order to capture these children who might otherwise not receive influenza immunization.

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        Complete influenza vaccination trends for children six to twenty-three months.
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