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Voluntary reporting of health care personnel seasonal influenza vaccination rates and the impact of universal policies in Illinois hospitals
Vaccine 31 (2013) 514–517
Contents lists available at SciVerse ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Voluntary reporting of health care personnel seasonal influenza vaccination rates and the impact of universal policies in Illinois hospitals Bonnie Paris a,∗ , Tracey Arahood a , Carl Asche b , Gail Amundson a a b
Quality Quest for Health of Illinois, Peoria, IL, USA Center for Health Outcomes Research, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
a r t i c l e
i n f o
Article history: Received 13 July 2012 Received in revised form 30 October 2012 Accepted 8 November 2012 Available online 20 November 2012 Keywords: Influenza vaccination Healthcare workers Public reporting
a b s t r a c t Objective: In 2009, voluntary public reporting of hospital health care personnel (HCP) vaccination rates began in Illinois. We describe our experience over 3 influenza seasons and examine the impact universal policies have had on performance. Methods: A secure website was used to report monthly HCP vaccination rates by each participating hospital. Overall and individual hospital performance was publicly reported each month. Results: In the first two seasons, there were 11 hospitals reporting with an average end of season rate of 76% (2009–2010) and 81% (2010–2011). In the 2011–2012 season, there were 22 hospitals reporting, 9 of which had a new universal policy for HCP influenza vaccination. The average 2011–2012 end of season rate was 72% for hospitals with a voluntary program and 95% for hospitals with a universal policy. HCP were also vaccinated earlier in the influenza season when a universal policy was in place, providing greater benefit over time. Conclusion: Public reporting of HCP influenza vaccination rates may contribute to implementation of universal employee vaccination policies. Hospitals with universal policies have higher vaccination rates than those with voluntary vaccination programs. © 2012 Elsevier Ltd. All rights reserved.
1. Introduction Seasonal influenza currently accounts for 3000–49,000 deaths in the US each year [1], an estimate that has remained stable over time [2,3]. The Centers for Disease Control (CDC) and state public health departments track the incidence of influenza, and each year a new vaccine is produced to provide immunity to the most prevalent strains [4]. Although influenza affects people of all ages, hospitalized and elderly patients are among the most vulnerable to long term influenza-related harm, including death [1,2,5]. The CDC now recommends annual influenza vaccination for all persons aged 6 months or older [5,6], but recommendations for hospital employee influenza vaccination have been longstanding [7]. There are significant costs associated with lost work time due to seasonal influenza [8,9]. Influenza vaccination of health care personnel (HCP) reduces the transmission of influenza, staff illness and absenteeism, and death among people prone to have severe complications of the disease [7,10,11]. There are a variety of approaches to increase the proportion of hospital HCP receiving annual influenza vaccination [7,8,12]. Joint Commission has a standard for
∗ Corresponding author at: Quality Quest for Health of Illinois, 416 Main Street, Suite 717, Peoria, IL 61602, USA. Tel.: +1 309 264 3656; fax: +1 309 637 0643. E-mail address: [email protected] (B. Paris). 0264-410X/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.vaccine.2012.11.025
hospital HCP influenza vaccination programs and started issuing annual “Flu Vaccination Challenges” in 2008 to provide public recognition for hospitals with HCP vaccination rates of 75% or greater [13]. Although some hospitals have adopted universal policies that require all HCP to receive the vaccination or wear a mask throughout the entire influenza season [12,14–16], current performance is well below the Healthy People 2020 target of 90% [17]. During the influenza season, Quality Quest for Health of Illinois makes hospital HCP influenza vaccination rates available to the public via its website [18] and through local news media [19,20]. In this paper we describe our experience with voluntary public reporting over 3 influenza seasons and we examine the impact universal vaccination policies have had on performance. We also consider the time to vaccinate, as more benefit arises when HCP receive the annual vaccination at the start of the influenza season rather than at the end.
2. Methods In 2009, Quality Quest for Health of Illinois began reporting hospital HCP influenza vaccination rates to the public via its website and through local news media. HCP vaccination rate is calculated as the percent of people who are employed at the institution who have received the seasonal influenza immunization. People employed
B. Paris et al. / Vaccine 31 (2013) 514–517
515
Table 1 Sample characteristics. Participating hospitals (N = 22) Total patient days Licensed beds by specialty Medical-surgical Pediatric Intensive care Obstetrics/gynecology Neonatal ICU Long-term care Acute mental illness Rehabilitation Long-term acute care Total beds set up for use
All Illinois hospitals [21] (N = 215)
Percent sampled
710,460
7,651,088
9%
2154 198 407 278 105 231 190 101 – 2911
21,678 1693 3372 2752 807 1510 3814 1643 821 32,537
10% 12% 12% 10% 13% 15% 5% 6% 0% 9%
at the institution include employed physicians but exclude volunteers, contract employees, and students. Although non-employees are excluded from this measure, they may participate in the free immunization programs within participating hospitals. Administration of the H1N1 immunization alone is not considered a seasonal influenza immunization. For the first two seasons, participating hospitals voluntarily reported monthly HCP influenza vaccination rates to Quality Quest using In 2011, participating hospitals entered the number of HCP vaccinated (numerator) and total number of HCP (denominator) using a secure online data portal for each hospital. This change in data collection procedure allowed us to calculate a weighted average by county. Each hospital had an online review period to verify the data prior to making the information available to the public. Quality Quest staff reviewed the data and contacted the data submitter when a data point was suspected of data entry error or misapplication of definition, prompting correction of data. Participation in public reporting of HCP vaccination rate is voluntary. In 2012, one hospital with below-average performance asked to have their data removed from the website, and this request was honored. We present the data from the 22 hospitals continuing to participate in voluntary public reporting of HCP influenza vaccination rate. We had participation from 10% of hospitals in Illinois [21]. Voluntary vaccination programs include hospital-sponsored clinics where all HCP are strongly encouraged to receive the seasonal influenza vaccination each year. A universal policy is distinguished by a requirement that all hospital HCP without medical contraindication or religious reason receive the seasonal influenza vaccination each year. Also, under a universal policy, there must be a valid reason documented for each employee who does not receive the seasonal influenza vaccination. Statistical analysis was performed using Microsoft Excel 2010 data analysis toolpak. An analysis of variance (ANOVA) with ˛ = 0.05 level of significance was performed to compare the HCP vaccination rate by policy type at the beginning and end of each flu season. A pairwise comparison of HCP vaccination rate before and after adoption of a universal policy was performed using the student-t distribution with = 0 and ˛ = 0.005 to compare HCP vaccination rate by policy type for each month of the flu season.
Table 2 HCP vaccination rates by policy type for 2011–2012 influenza season. Mean Beginning of influenza season 83.6 Universal 62.9 Voluntary End of influenza season Universal 94.3 Voluntary 72.0
Standard deviation
N
7.9 13.2
14 7
4.2 11.1
15 7
p-Value 0.0002
<0.0001
Of the 11 hospitals that began reporting in 2009 and continued through 2012, 9 (82%) implemented a universal policy in 2011. Of the 11 hospitals that began public reporting in 2011, 6 (55%) had a universal policy. The beginning of season rate for 2011–2012 was 65% for hospitals with a voluntary program and 84% for hospitals with a universal policy. The end of season rate for 2011–2012 was 72% for hospitals with a voluntary program and 95% for hospitals with a universal policy. Please refer to Fig. 1. At the ˛ = 0.05 level, there is a statistically significant difference in vaccination rate by type of policy at both the beginning of the influenza season and the end of the influenza season. Please refer to Table 2 for additional details. Compared to hospitals with a voluntary program, the mean HCP vaccination rate of hospitals with a universal policy was 20.7% greater at the beginning of the flu season and 22.3% greater at the end of the flu season. For the 9 hospitals that adopted a universal policy in 2011 and began public reporting in 2009, we performed pairwise comparisons between HCP vaccination rates when a voluntary program was in place (2009–2010 influenza season and 2010–2011 influenza season) and a universal policy was in place (2011–2012 influenza season). With a hypothesized mean difference of 0 and ˛ = 0.005, six of eight pairwise comparisons showed a statistically significant difference in HCP vaccination rate by type of policy. The comparisons that did not show a statistically significant difference
3. Results In the first two seasons, there were 11 hospitals reporting with an average end of season rate of 76% for the 2009–2010 season and 81% for the 2010–2011 season. In the 2011–2012 season, there were 22 hospitals reporting, 9 of which had a new universal policy for HCP influenza vaccination. Our sample includes 2 teaching hospitals, 13 general hospitals, and 7 critical access hospitals. Please refer to Table 1 for additional sample characteristics.
Fig. 1. Average of hospital employee vaccination rates by influenza season and policy type.
516
B. Paris et al. / Vaccine 31 (2013) 514–517
Table 3 Results of paired t-tests comparing type of policy. Month
Voluntary period
Universal period
N
p-Value
October October November November December December January February
2009–2010 2010–2011 2009–2010 2010–2011 2009–2010 2010–2011 2010–2011 2010–2011
2011–2012 2011–2012 2011–2012 2011–2012 2011–2012 2011–2012 2011–2012 2011–2012
3 7 4 9 9 9 9 9
0.1561 0.0014 0.0124 0.0004 0.0002 0.0003 0.0003 0.0003
lacked power to detect, with only 3 paired and 4 paired observations available for analysis. The results of the paired t-tests are presented in Table 3.
participated in the flu reporting project for 2011–2012: Carle Foundation Hospital*, Urbana; Decatur Memorial Hospital*, Decatur; Genesis Medical Center*, Silvis; Hoopeston Regional Health Center, Hoopeston; Illini Community Hospital* (Blessing Health System), Pittsfield; Massac Memorial Hospital, Metropolis; Methodist Medical Center of Illinois, Peoria; OSF Holy Family*, Monmouth; OSF Saint Anthony Medical Center*, Rockford; OSF Saint Francis Medical Center*, Peoria; OSF Saint James – John W. Albrecht Medical Center*, Pontiac; OSF Saint Joseph Medical Center*, Bloomington; OSF Saint Mary Medical Center*, Galesburg; Ottawa Regional Hospital and Healthcare Center*, Ottawa; Pana Community Hospital, Pana; Pekin Hospital, Pekin; Pinckneyville Community Hospital*, Pinckneyville; Proctor Hospital*, Peoria; St. John’s Hospital*, Springfield; St. Mary’s Hospital*, Decatur; Union County Hospital, Anna; Washington County Hospital*, Nashville.
4. Discussion
References
Our experience in Illinois mimics the experience in Iowa, with hospitals engaged in public reporting of HCP vaccination rates implementing universal policies after a few years [14,15]. Previous research has found increases in HCP vaccination rates between 8.6% and 39.8% associated with universal HCP vaccination policies [12,14,15]. However, this research considers end of season performance only. It is also unclear whether or not hospital type (e.g., teaching, critical access) is a contributing factor to hospital employee vaccination rates. Our study does not consider hospital type due to the resulting insufficient sample size from the addition of another variable. However, in our analysis we used a pairwise comparison technique to control for hospital-related factors. Comparing the same hospital to itself over time, and before and after implementation of a universal policy, is a strength of our study. A limitation of our study is the potential for bias in the voluntary reporting of results. We have had one hospital withdraw its commitment to public reporting of employee influenza vaccination results. Although this hospital was in the lower quartile, it was not the hospital with the lowest rate of HCP vaccination. A systematic review of the cost-effectiveness of pneumococcal vaccinations has found a sizeable variation in the current assessments of cost-effectiveness due, in part, to the uncertainty in the effectiveness of vaccinations [22]. Vaccinations against influenza have been associated with reductions in the rates of hospitalizations and in mortality associated with influenza and related complications as compared to the rates found in unvaccinated individuals [23]. Findings from other case–control studies also demonstrated significant reductions in the rates of hospitalizations for influenza during the same approximate time frame [24–26]. These savings would even be more pronounced if the studies had estimated the savings associated with the reduction of outpatient health care resources. As such, influenza vaccinations are credited with saving healthcare costs and improving survival rates [23]. A variety of factors may contribute to the rate of hospital HCP influenza vaccination. The recent change in guidelines for the general adult population may also contribute to observed increases in hospital HCP vaccination rates. There is growing evidence that implementation of a universal policy contributes to a dramatic increase in performance.
[1] Thompson WW, Shay DK, Weintraub E, Brammer L, Cox N, Anderson LJ, et al. Mortality associated with influenza and respiratory syncytial virus in the United States. JAMA 2003;289(2):179–86. [2] Centers for Disease Control Prevention. Estimates of deaths associated with seasonal influenza – United States, 1976–2007. MMWR Morb Mortal Wkly Rep 2010;59(33):1057–62. [3] Simonsen L, Clarke MJ, Williamson GD, Stroup DF, Arden NH, Schonberger LB. The impact of influenza epidemics on mortality: introducing severity index. Am J Public Health 1997;87(12):1944–50. [4] Centers for Disease Control and Prevention. Seasonal Influenza Questions and Answers. Available at: http://www.cdc.gov/flu/about/qa/disease.htm (accessed 8.10.12). [5] Centers for Disease Control Prevention (CDC). Prevention and control of influenza with vaccines: recommendations of the advisory committee on immunization practices (ACIP) – United States, 2012–13 influenza season. MMWR Morb Mortal Rep 2011;61(32):613–8. [6] Centers for Disease Control Prevention, National Center for Immunization Respiratory Diseases. General recommendations on immunization: recommendations of the advisory committee on immunization practices (ACIP). MMWR Recomm Rep 2011;60(2):1–64. [7] Centers for Disease Control Prevention. Immunization of health-care personnel: recommendations of the advisory committee on immunization practices (ACIP). MMWR Recomm Rep 2011;60(RR-7):1–45. [8] Dash GP, Fauerbach L, Pfeiffer J, Soule B, Bartley J, Barnard B, et al. APIC position paper: improving health care worker influenza immunization rates. Am J Infect Control 2004;32(3):123–5. [9] Lee BY, Bailey RR, Wiringa AE, Afriyie A, Wateska AR, Smith KJ, et al. Economics of employer-sponsored workplace vaccination to prevent pandemic and seasonal influenza. Vaccine 2010;28(37):5952–9. [10] Turnberg W, Daniell W, Duchin J. Influenza vaccination and sick leave practices and perceptions reported by health care workers in ambulatory care settings. Am J Infect Control 2010;38(6):486–8. [11] Apisarnthanarak A, Uyeki T, Puthavathana P, Kitpathi R, Mundi L. Reduction of seasonal influenza transmission among healthcare workers in an intensive care unit: a 4-year intervention study in Thailand. Infect Control Hosp Epidemiol 2010;31(10):996–1003. [12] Centers for Disease Control Prevention. Influenza vaccination coverage among health-care personnel – United States, 2010–11 influenza season. MMWR Morb Mortal Wkly Rep 2011;60(32):1073–7. [13] Joint Commission Resources. Health Care Workers Achieve 80 Percent Influenza Vaccination Average for the 2010–2011 Influenza Season: Influenza Vaccination Challenge Participants Surpass National Average for Health Care Workers. Available at: http://www.jcrinc.com/FVC-In-the-News/ (accessed 8.10.12). [14] Helms C, Polgreen P, Polgreen L, Evans T, Roberts LL, Clabaugh G, et al. Voluntary reporting of employee influenza vaccination rates by acute care hospitals in Iowa: the impact of a four year provider-based statewide improvement project. Vaccine 2011;29(18):3483–8. [15] Polgreen PM, Polgreen LA, Evans T, Helms C. A statewide system for improving influenza vaccination rates in hospital employees. Infect Control Hosp Epidemiol 2009;30(5):474–8. [16] Miller BL, Ahmed F, Lindley MC, Wortley PM. Increases in vaccination coverage of healthcare personnel following institutional requirements for influenza vaccination: a national survey of US hospitals. Vaccine 2011;29(50):9398–403. [17] US Department of Health and Human Services. Healthy People 2020 Objectives for Health Care Personnel. Available at: http://www. healthypeople.gov/2020/topicsobjectives2020/objectiveslist.aspx?topicId=23 (accessed on 8.10.12). [18] Quality Quest for Health of Illinois. Hospital Employee Flu Reporting. Available at: http://www.qualityquest. Vaccination org/quality-reports/flu shot measure/index.php (accessed 8.10.12). [19] Amundson, G. In the spotlight: more health care workers receiving flu vaccine. Peoria Journal Star. February 13, 2011. Available at:
Acknowledgements Quality Quest for Health of Illinois thanks the hospitals that embraced voluntary public reporting of HCP influenza vaccination rates for their participation. The asterisk (*) indicates that the hospital has a universal vaccination policy. The following hospitals
B. Paris et al. / Vaccine 31 (2013) 514–517 http://www.pjstar.com/opinion/spotlight/x1463449564/In-the-SpotlightMore-health-care-workers-receiving-flu-vaccine (accessed 8.10.12). [20] Adams P. Flu cases on the rise in Central Illinois. Peoria Journal Star. March 9, 2012. Available at: http://www.pjstar.com/news/x1617889831/Flu-cases-onthe-rise-in-central-Illinois (accessed 8.10.12). [21] Illinois Health Facilities and Services Review Board. 2010 Hospital Profiles and Annual Bed Reports. Available at http://www.idph. state.il.us/about/hfpb/HospProf ABR.htm (accessed 8.10.12). [22] Hutton J, Iglesias C, Jefferson TO. Assessing the potential cost effectiveness of pneumococcal vaccines in the US: methodological issues and current evidence. Drugs Aging 1999;15:31–6.
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[23] Nichol KL, Margolis KL, Wuorenma J, Von Sternberg T. The efficacy and cost effectiveness of vaccination against influenza among elderly persons living in the community. N Engl J Med 1994;331(12):778–84. [24] Fedson DS, Wajda A, Nicol JP, Hammond GW, Kaiser DL, Roos LL. Clinical effectiveness of influenza vaccination in Manitoba. JAMA 1993;270:1956–61. [25] Foster DA, Talsma A, Furumoto-Dawson A, Ohmit SE, Margulies JR, Arden NH, et al. Influenza vaccine effectiveness in preventing hospitalization for pneumonia in the elderly. Am J Epidemiol 1992;136(3):296–307. [26] Mullooly JP, Bennett MD, Hornbrook MC, Barker WH, Williams WW, Patriarca PA, et al. Influenza vaccination programs for elderly persons: cost-effectiveness in a health maintenance organization. Ann Intern Med 1994;121(12):947–52.
Contents lists available at SciVerse ScienceDirect
Vaccine journal homepage: www.elsevier.com/locate/vaccine
Voluntary reporting of health care personnel seasonal influenza vaccination rates and the impact of universal policies in Illinois hospitals Bonnie Paris a,∗ , Tracey Arahood a , Carl Asche b , Gail Amundson a a b
Quality Quest for Health of Illinois, Peoria, IL, USA Center for Health Outcomes Research, University of Illinois College of Medicine at Peoria, Peoria, IL, USA
a r t i c l e
i n f o
Article history: Received 13 July 2012 Received in revised form 30 October 2012 Accepted 8 November 2012 Available online 20 November 2012 Keywords: Influenza vaccination Healthcare workers Public reporting
a b s t r a c t Objective: In 2009, voluntary public reporting of hospital health care personnel (HCP) vaccination rates began in Illinois. We describe our experience over 3 influenza seasons and examine the impact universal policies have had on performance. Methods: A secure website was used to report monthly HCP vaccination rates by each participating hospital. Overall and individual hospital performance was publicly reported each month. Results: In the first two seasons, there were 11 hospitals reporting with an average end of season rate of 76% (2009–2010) and 81% (2010–2011). In the 2011–2012 season, there were 22 hospitals reporting, 9 of which had a new universal policy for HCP influenza vaccination. The average 2011–2012 end of season rate was 72% for hospitals with a voluntary program and 95% for hospitals with a universal policy. HCP were also vaccinated earlier in the influenza season when a universal policy was in place, providing greater benefit over time. Conclusion: Public reporting of HCP influenza vaccination rates may contribute to implementation of universal employee vaccination policies. Hospitals with universal policies have higher vaccination rates than those with voluntary vaccination programs. © 2012 Elsevier Ltd. All rights reserved.
1. Introduction Seasonal influenza currently accounts for 3000–49,000 deaths in the US each year [1], an estimate that has remained stable over time [2,3]. The Centers for Disease Control (CDC) and state public health departments track the incidence of influenza, and each year a new vaccine is produced to provide immunity to the most prevalent strains [4]. Although influenza affects people of all ages, hospitalized and elderly patients are among the most vulnerable to long term influenza-related harm, including death [1,2,5]. The CDC now recommends annual influenza vaccination for all persons aged 6 months or older [5,6], but recommendations for hospital employee influenza vaccination have been longstanding [7]. There are significant costs associated with lost work time due to seasonal influenza [8,9]. Influenza vaccination of health care personnel (HCP) reduces the transmission of influenza, staff illness and absenteeism, and death among people prone to have severe complications of the disease [7,10,11]. There are a variety of approaches to increase the proportion of hospital HCP receiving annual influenza vaccination [7,8,12]. Joint Commission has a standard for
∗ Corresponding author at: Quality Quest for Health of Illinois, 416 Main Street, Suite 717, Peoria, IL 61602, USA. Tel.: +1 309 264 3656; fax: +1 309 637 0643. E-mail address: [email protected] (B. Paris). 0264-410X/$ – see front matter © 2012 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.vaccine.2012.11.025
hospital HCP influenza vaccination programs and started issuing annual “Flu Vaccination Challenges” in 2008 to provide public recognition for hospitals with HCP vaccination rates of 75% or greater [13]. Although some hospitals have adopted universal policies that require all HCP to receive the vaccination or wear a mask throughout the entire influenza season [12,14–16], current performance is well below the Healthy People 2020 target of 90% [17]. During the influenza season, Quality Quest for Health of Illinois makes hospital HCP influenza vaccination rates available to the public via its website [18] and through local news media [19,20]. In this paper we describe our experience with voluntary public reporting over 3 influenza seasons and we examine the impact universal vaccination policies have had on performance. We also consider the time to vaccinate, as more benefit arises when HCP receive the annual vaccination at the start of the influenza season rather than at the end.
2. Methods In 2009, Quality Quest for Health of Illinois began reporting hospital HCP influenza vaccination rates to the public via its website and through local news media. HCP vaccination rate is calculated as the percent of people who are employed at the institution who have received the seasonal influenza immunization. People employed
B. Paris et al. / Vaccine 31 (2013) 514–517
515
Table 1 Sample characteristics. Participating hospitals (N = 22) Total patient days Licensed beds by specialty Medical-surgical Pediatric Intensive care Obstetrics/gynecology Neonatal ICU Long-term care Acute mental illness Rehabilitation Long-term acute care Total beds set up for use
All Illinois hospitals [21] (N = 215)
Percent sampled
710,460
7,651,088
9%
2154 198 407 278 105 231 190 101 – 2911
21,678 1693 3372 2752 807 1510 3814 1643 821 32,537
10% 12% 12% 10% 13% 15% 5% 6% 0% 9%
at the institution include employed physicians but exclude volunteers, contract employees, and students. Although non-employees are excluded from this measure, they may participate in the free immunization programs within participating hospitals. Administration of the H1N1 immunization alone is not considered a seasonal influenza immunization. For the first two seasons, participating hospitals voluntarily reported monthly HCP influenza vaccination rates to Quality Quest using In 2011, participating hospitals entered the number of HCP vaccinated (numerator) and total number of HCP (denominator) using a secure online data portal for each hospital. This change in data collection procedure allowed us to calculate a weighted average by county. Each hospital had an online review period to verify the data prior to making the information available to the public. Quality Quest staff reviewed the data and contacted the data submitter when a data point was suspected of data entry error or misapplication of definition, prompting correction of data. Participation in public reporting of HCP vaccination rate is voluntary. In 2012, one hospital with below-average performance asked to have their data removed from the website, and this request was honored. We present the data from the 22 hospitals continuing to participate in voluntary public reporting of HCP influenza vaccination rate. We had participation from 10% of hospitals in Illinois [21]. Voluntary vaccination programs include hospital-sponsored clinics where all HCP are strongly encouraged to receive the seasonal influenza vaccination each year. A universal policy is distinguished by a requirement that all hospital HCP without medical contraindication or religious reason receive the seasonal influenza vaccination each year. Also, under a universal policy, there must be a valid reason documented for each employee who does not receive the seasonal influenza vaccination. Statistical analysis was performed using Microsoft Excel 2010 data analysis toolpak. An analysis of variance (ANOVA) with ˛ = 0.05 level of significance was performed to compare the HCP vaccination rate by policy type at the beginning and end of each flu season. A pairwise comparison of HCP vaccination rate before and after adoption of a universal policy was performed using the student-t distribution with = 0 and ˛ = 0.005 to compare HCP vaccination rate by policy type for each month of the flu season.
Table 2 HCP vaccination rates by policy type for 2011–2012 influenza season. Mean Beginning of influenza season 83.6 Universal 62.9 Voluntary End of influenza season Universal 94.3 Voluntary 72.0
Standard deviation
N
7.9 13.2
14 7
4.2 11.1
15 7
p-Value 0.0002
<0.0001
Of the 11 hospitals that began reporting in 2009 and continued through 2012, 9 (82%) implemented a universal policy in 2011. Of the 11 hospitals that began public reporting in 2011, 6 (55%) had a universal policy. The beginning of season rate for 2011–2012 was 65% for hospitals with a voluntary program and 84% for hospitals with a universal policy. The end of season rate for 2011–2012 was 72% for hospitals with a voluntary program and 95% for hospitals with a universal policy. Please refer to Fig. 1. At the ˛ = 0.05 level, there is a statistically significant difference in vaccination rate by type of policy at both the beginning of the influenza season and the end of the influenza season. Please refer to Table 2 for additional details. Compared to hospitals with a voluntary program, the mean HCP vaccination rate of hospitals with a universal policy was 20.7% greater at the beginning of the flu season and 22.3% greater at the end of the flu season. For the 9 hospitals that adopted a universal policy in 2011 and began public reporting in 2009, we performed pairwise comparisons between HCP vaccination rates when a voluntary program was in place (2009–2010 influenza season and 2010–2011 influenza season) and a universal policy was in place (2011–2012 influenza season). With a hypothesized mean difference of 0 and ˛ = 0.005, six of eight pairwise comparisons showed a statistically significant difference in HCP vaccination rate by type of policy. The comparisons that did not show a statistically significant difference
3. Results In the first two seasons, there were 11 hospitals reporting with an average end of season rate of 76% for the 2009–2010 season and 81% for the 2010–2011 season. In the 2011–2012 season, there were 22 hospitals reporting, 9 of which had a new universal policy for HCP influenza vaccination. Our sample includes 2 teaching hospitals, 13 general hospitals, and 7 critical access hospitals. Please refer to Table 1 for additional sample characteristics.
Fig. 1. Average of hospital employee vaccination rates by influenza season and policy type.
516
B. Paris et al. / Vaccine 31 (2013) 514–517
Table 3 Results of paired t-tests comparing type of policy. Month
Voluntary period
Universal period
N
p-Value
October October November November December December January February
2009–2010 2010–2011 2009–2010 2010–2011 2009–2010 2010–2011 2010–2011 2010–2011
2011–2012 2011–2012 2011–2012 2011–2012 2011–2012 2011–2012 2011–2012 2011–2012
3 7 4 9 9 9 9 9
0.1561 0.0014 0.0124 0.0004 0.0002 0.0003 0.0003 0.0003
lacked power to detect, with only 3 paired and 4 paired observations available for analysis. The results of the paired t-tests are presented in Table 3.
participated in the flu reporting project for 2011–2012: Carle Foundation Hospital*, Urbana; Decatur Memorial Hospital*, Decatur; Genesis Medical Center*, Silvis; Hoopeston Regional Health Center, Hoopeston; Illini Community Hospital* (Blessing Health System), Pittsfield; Massac Memorial Hospital, Metropolis; Methodist Medical Center of Illinois, Peoria; OSF Holy Family*, Monmouth; OSF Saint Anthony Medical Center*, Rockford; OSF Saint Francis Medical Center*, Peoria; OSF Saint James – John W. Albrecht Medical Center*, Pontiac; OSF Saint Joseph Medical Center*, Bloomington; OSF Saint Mary Medical Center*, Galesburg; Ottawa Regional Hospital and Healthcare Center*, Ottawa; Pana Community Hospital, Pana; Pekin Hospital, Pekin; Pinckneyville Community Hospital*, Pinckneyville; Proctor Hospital*, Peoria; St. John’s Hospital*, Springfield; St. Mary’s Hospital*, Decatur; Union County Hospital, Anna; Washington County Hospital*, Nashville.
4. Discussion
References
Our experience in Illinois mimics the experience in Iowa, with hospitals engaged in public reporting of HCP vaccination rates implementing universal policies after a few years [14,15]. Previous research has found increases in HCP vaccination rates between 8.6% and 39.8% associated with universal HCP vaccination policies [12,14,15]. However, this research considers end of season performance only. It is also unclear whether or not hospital type (e.g., teaching, critical access) is a contributing factor to hospital employee vaccination rates. Our study does not consider hospital type due to the resulting insufficient sample size from the addition of another variable. However, in our analysis we used a pairwise comparison technique to control for hospital-related factors. Comparing the same hospital to itself over time, and before and after implementation of a universal policy, is a strength of our study. A limitation of our study is the potential for bias in the voluntary reporting of results. We have had one hospital withdraw its commitment to public reporting of employee influenza vaccination results. Although this hospital was in the lower quartile, it was not the hospital with the lowest rate of HCP vaccination. A systematic review of the cost-effectiveness of pneumococcal vaccinations has found a sizeable variation in the current assessments of cost-effectiveness due, in part, to the uncertainty in the effectiveness of vaccinations [22]. Vaccinations against influenza have been associated with reductions in the rates of hospitalizations and in mortality associated with influenza and related complications as compared to the rates found in unvaccinated individuals [23]. Findings from other case–control studies also demonstrated significant reductions in the rates of hospitalizations for influenza during the same approximate time frame [24–26]. These savings would even be more pronounced if the studies had estimated the savings associated with the reduction of outpatient health care resources. As such, influenza vaccinations are credited with saving healthcare costs and improving survival rates [23]. A variety of factors may contribute to the rate of hospital HCP influenza vaccination. The recent change in guidelines for the general adult population may also contribute to observed increases in hospital HCP vaccination rates. There is growing evidence that implementation of a universal policy contributes to a dramatic increase in performance.
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Acknowledgements Quality Quest for Health of Illinois thanks the hospitals that embraced voluntary public reporting of HCP influenza vaccination rates for their participation. The asterisk (*) indicates that the hospital has a universal vaccination policy. The following hospitals
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