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Effect of a multi-modal intervention on immunization rates in obstetrics and gynecology clinics

Published:November 25, 2015DOI:https://doi.org/10.1016/j.ajog.2015.11.018

      Background

      There is increasing attention on immunizations by obstetrician-gynecologists and a need to improve vaccination rates for all women.

      Objective

      To evaluate the effect of a multimodal intervention on rates of immunization with tetanus, diphtheria, and acellular pertussis (Tdap); human papillomavirus (HPV); and influenza in outpatient obstetrics and gynecology clinics.

      Study Design

      Immunization rates at 2 clinics were compared pre- and post-implementation of multiple interventions at a public integrated health-care system. Study interventions began on June 6, 2012 and concluded on May 31, 2014; the preimplementation time period used was June 6, 2010 to June 5, 2012. Interventions included stocking of immunizations in clinics, revision and expansion of standing orders, creation of a reminder/recall program, identification of an immunization champion to give direct provider feedback, expansion of a payment assistance program, and staff education. All women aged 15 and older who made a clinic visit during influenza season were included in the influenza cohort; women who delivered an infant during the study time period and had at least 1 prenatal visit within 9 months preceding delivery were included in the Tdap cohort; each clinic visit by a nonpregnant woman aged 15–26 years was assessed and included in the HPV analysis as an eligible visit if the patient was lacking any of the 3 HPV vaccines in the series. The primary outcome was receipt of influenza and Tdap vaccine per current American College of Obstetricians and Gynecologists guidelines and receipt of HPV vaccine during eligible visits. Influenza and Tdap were assessed with overall coverage rates at the institutional level, and HPV was assessed at the visit level by captured opportunities. All analyses included generalized estimating equations and the primary outcome was assessed with time as a covariate in all models.

      Results

      A total of 19,409 observations were included in the influenza cohort (10,231 pre- and 9178 post-intervention), 2741 in the Tdap cohort (1248 pre- and 1493 post-intervention), and 12,443 in the HPV cohort (7966 pre- and 4477 post-intervention). Our population was largely Hispanic, English-speaking, and publicly insured. The rate of influenza vaccination increased from 35.4% pre-intervention to 46.0% post-intervention (P < .001). The overall rate for Tdap vaccination increased from 87.6% pre-intervention to 94.5% post-intervention until the recommendation to vaccinate during each pregnancy was implemented (z = 4.58, P < .0001). The average Tdap up-to-date rate after that recommendation was 75.0% (z = -5.77, P < .0001). The overall rate of HPV vaccination with an eligible visit increased from 7.1% before to 23.7% after the intervention.

      Conclusion

      Using evidence-based practices largely established in other settings, our intervention was associated with increased rates of influenza, Tdap, and HPV vaccination in outpatient underserved obstetrics and gynecology clinics. Integrating such evidence-based practices into routine obstetrics and gynecology care could positively impact preventive health for many women.

      Key words

      There is increasing attention on immunizations in the obstetrics and gynecology setting. The American College of Obstetricians and Gynecologists (ACOG) has strengthened its efforts to improve immunization practices in the field and states that “obstetrician-gynecologists should embrace immunizations as an integral part of their women’s health care practice.”
      American College of Obstetricians and Gynecologists
      Committee Opinion Number 558: integrating immunizations into practice.
      Pregnant women are a priority population for vaccines,
      • Swamy G.K.
      • Heine R.P.
      Vaccinations for pregnant women.
      • MacDonald N.E.
      • Riley L.E.
      • Steinhoff M.C.
      Influenza immunization in pregnancy.
      and obstetrician-gynecologists (ob-gyns) are uniquely positioned to provide immunizations for all women. Approximately 20% of women making an ambulatory visit to an ob-gyn office identify their ob-gyn as their primary care provider,

      CDC, National Center for Health Statistics, National Ambulatory Medical Care Survey, 2010. Available at: http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf. Accessed May 5, 2015.

      and ob-gyns provide more office-based well-woman care than any other type of provider.
      • Leader S.
      • Perales P.J.
      Provision of primary-preventive health care services by obstetrican-gynecologists.
      As such, ob-gyns play a vital role in the provision of immunizations as part of preventive care for women.
      There is particular attention paid to 3 specific vaccines for young, healthy women: tetanus, diphtheria, and acellular pertussis (Tdap); human papillomavirus (HPV); and influenza. The Advisory Committee on Immunization Practices (ACIP) recommends the influenza vaccine for everyone aged 6 months and older as a strategy to prevent flu-related illness in all people,
      Centers for Disease Control and Prevention
      Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices (ACIP) – United States, 2014-15 influenza season.
      and pregnant women are a priority population. Pertussis incidence has significantly increased in recent years, with rates approaching the prevaccine era.

      Centers for Disease Control and Prevention. Pertussis outbreak trends. Available at: http://www.cdc.gov/pertussis/outbreaks/trends.html. Accessed May 5, 2015.

      Infants under 1 year of age are at the highest risk of pertussis morbidity and mortality. As a strategy to protect infants via passive immunization, both ACIP and ACOG now recommend that women receive a Tdap vaccine with each pregnancy.
      Centers for Disease Control and Prevention. Updated recommendations for use of tetanus toxoid reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women—Advisory Committee on Immunization Practices (ACIP), 2012.
      American College of Obstetricians and Gynecologists
      Committee Opinion Number 566: update on immunization and pregnancy: Tetanus, diphtheria, and pertussis vaccination.
      HPV is the most common sexually transmitted infection in the United States.

      Centers for Disease Control. Human papillomavirus (HPV). Available at: http://www.cdc.gov/hpv/index.html. Accessed Feb 9, 2015.

      In addition to the more than 1 million abnormal cervical cancer screening results that require evaluation, approximately 4000 women die from HPV-related cervical cancer annually.
      • Insinga R.P.
      • Glass A.G.
      • Rush B.B.
      The health care costs of cervical human papillomavirus-related disease.
      To reduce both benign and malignant HPV-associated disease, the HPV vaccine is recommended for all girls aged 11–12 with catch-up through age 26.
      • Markowitz L.E.
      • Dunne E.F.
      • Saraiya M.
      • et al.
      for Centers for Disease Control. Human papillomavirus vaccination: recommendations of the Advisory Committee on Immunization Practices (ACIP).
      Adult vaccination rates remain low in the United States.
      Centers for Disease Control and Prevention. Noninfluenza vaccination coverage among adults – United States, 2012.
      The Centers for Disease Control and other authorities have called for improvements in adult vaccination to reduce the health consequences of vaccine-preventable diseases among adults and to prevent infectious morbidity and mortality in their infants.
      National Vaccine Advisory Committee
      Recommendations from the National Vaccine Advisory Committee: Standards for adult immunization practice.
      Best practices that have been shown to improve immunization rates include reminder/recall systems, efforts to remove administrative and financial barriers to vaccination, use of standing order programs for vaccination, and assessment of practice-level vaccination rates coupled with feedback to staff members.

      Community Preventive Services Task Force. The guide to community preventive services. Increasing appropriate vaccination. US Department of Health and Human Services, CDC. Available at: http://www.thecommunityguide.org/vaccines/index.html. Accessed Feb 9, 2015.

      The majority of data used to establish these best practices come from pediatric or inpatient adult populations, although investigators have used novel interventions such as text-messaging, automated reminders and computer alerts, and decision support to improve influenza, Tdap, and HPV vaccination in outpatient adult women.
      • Patel A.
      • Stern L.
      • Unger Z.
      • Debevec E.
      • Roston A.
      • Hanover R.
      • et al.
      Staying on track: a cluster randomized controlled trial of automated reminders aimed at increasing human papillomavirus vaccine completion.
      • Klatt T.E.
      • Hopp E.
      Effect of a best-practice alert on the rate of influenza vaccination of pregnant women.
      • Mouzoon M.E.
      • Munoz F.M.
      • Greisinger A.J.
      • et al.
      Improving influenza immunization in pregnant women and healthcare workers.
      • Stockwell M.S.
      • Westhoff C.
      • Kharbanda E.O.
      • et al.
      Influenza vaccine text message reminders for urban, low-income pregnant women: a randomized controlled trial.
      • Moniz M.H.
      • Hasley S.
      • Meyn L.A.
      • Beigi R.H.
      Improving influenza vaccination rates in pregnancy through text messaging: a randomized controlled trial.
      We aimed to increase the immunization rates of influenza, Tdap, and HPV in underserved outpatient ob-gyn clinics by using established evidence-based strategies in a multimodal intervention, and in this report we present our evaluation of the intervention.

      Materials and Methods

      Study setting

      We performed a pre–post assessment of a multimodal intervention in 2 community-based ob-gyn clinics. Both clinics are part of Denver Health and Hospitals (DHH), an integrated safety-net health-care system with 8 community health centers and a central urban 500-bed public hospital, all using a common electronic medical record (EMR). An electronic clinical decision support tool including standing orders for immunizations was implemented in the DHH adult primary care clinics in 2007; however, this tool was not routinely used in DHH ob-gyn clinics until 2011. Obstetrics and gynecology care at our institution is provided by ob-gyn faculty and residents, family medicine faculty and residents, nurse practitioners, or certified nurse midwives at each health center and the hospital. Two women’s care clinics staffed primarily by certified nurse midwives with ob-gyn faculty oversight were included in this trial. These 2 clinics have approximately 7950 and 12,600 visits per year; the majority of patients are publicly insured or uninsured. This study was approved by the Colorado Multiple Institutional Review Board.

      Study period

      The study interventions began on June 6, 2012 and concluded on May 31, 2014. During the planning and implementation of the study, there were significant changes in ACIP and ACOG recommendations for Tdap vaccination in pregnant women. In March 2012, ACOG recommended the Tdap vaccine during pregnancy rather than immediately postpartum if not vaccinated previously (recommendation 1). This recommendation was approved by DHH and implemented in the study sites in June 2012. In June 2013, ACOG endorsed the ACIP updated guidelines to recommend that Tdap be administered during each pregnancy, irrespective of the patient’s prior Tdap vaccine history (recommendation 2). This change was approved and implemented at our institution in August 2013. No other institutional systematic changes pertinent to either clinic’s processes were implemented during the study time period. The 2 years preceding study interventions (June 6, 2010 through June 5, 2012) were used as the preintervention time period.

      Study interventions

      Study interventions are summarized in Table 1. Most activities were aimed at improving standard processes for all immunizations in the clinics and were derived from evidence-based practices shown to increase vaccination rates. First, we provided education for nonprovider medical staff to raise awareness and empower them in their vital role in provision of immunizations. All medical staff at both clinics were required to attend 2 sessions, 1 on HPV and the other on Tdap in pregnancy. Standing orders for vaccines already in place were revised or expanded depending on the vaccine. The electronic clinical decision support tool is queried for each patient as they are triaged for a clinic visit for vaccine standing orders. Prior to the intervention, this tool would only provide a standing order for a vaccine if the vaccine was covered by insurance. This was revised to provide an order for all indicated vaccines regardless of insurance. The standing orders were also expanded to include influenza in the outpatient setting, as previous to the intervention there was only a standing order for influenza vaccine on the inpatient wards. Billing was not identified as an obstacle to immunization and was not addressed in this intervention. A single immunization champion was identified for both clinics. This was a registered nurse who performed periodic chart reviews and gave immediate feedback to providers when missed opportunities were identified. Additionally, at each clinic, a medical assistant who had the highest rates of vaccination prior to the intervention was given recognition at her clinic by receiving institutional awards. At the conclusion of the first year, 10 staff members were interviewed about the new processes and this midpoint qualitative feedback was used to improve and expand interventions.
      Table 1Interventions by immunization
      Interventions derived from Community Preventive Services Task Force.15
      AllStanding order revised and expanded

      Clinic immunization champion identified

      Immunization education sessions for nonprovider staff

      Periodic chart reviews with immediate provider feedback
      HPVMerck Assistance Program expanded

      Reminder/recall program implemented

      Standing order revised to include uninsured
      InfluenzaAntenatal paper chart forms revised to prompt 3 refusals
      TdapImmunization stocked in clinic

      Staff trainings regarding new recommendations

      Antenatal paper chart forms revised to include standing order and prompt 3 refusals

      Patient and family handouts created
      HPV, human papillomavirus; Tdap, tetanus, diphtheria, and acellular pertussis.
      Mazzoni et al. Immunization in ob-gyn clinics. Am J Obstet Gynecol 2016.
      a Interventions derived from Community Preventive Services Task Force.

      Community Preventive Services Task Force. The guide to community preventive services. Increasing appropriate vaccination. US Department of Health and Human Services, CDC. Available at: http://www.thecommunityguide.org/vaccines/index.html. Accessed Feb 9, 2015.

      The practice changes regarding Tdap required additional interventions. First, each clinic began stocking and administering Tdap, as this was the only of the 3 vaccines not available in ob-gyn clinics prior to the intervention. Additional staff trainings including providers were held with each recommendation change. Patient handouts were created and routinely given out at each first prenatal visit and at ultrasound visits. Although DHH uses an EMR, each obstetrics patient also has a paper chart, which is then scanned into the EMR. The antenatal paper chart forms were revised to include a standing order for Tdap, as the electronic support tool cannot recognize pregnancy and does not function in this setting. The revised form also provided a space for documentation of vaccine discussions and enforced the intervention requirement of 3 documented Tdap and/or influenza vaccine refusals among patients who declined vaccination.
      Lack of insurance was identified as a barrier, especially for HPV vaccine; women without any form of insurance are required to pay the complete out-of-pocket cost for the vaccine, while women with insurance are not required to pay anything additional. Not only is HPV the most costly of the 3 vaccines, but nonpregnant women eligible for the vaccine are more likely to be uninsured compared to the pregnant population included in the Tdap and influenza cohorts, as pregnancy is always covered by some type of insurance in our state. Prior to the study interventions, a program through which uninsured patients can apply to receive the vaccine for free was available at only 1 of the clinics. This program was expanded to include both sites, the paperwork for the assistance program was streamlined, and, as mentioned above, the electronic standing order was revised to include uninsured patients. A reminder/recall program was also instituted to notify patients when second and third doses were due. Upon receipt of their first dose of HPV, patients were asked if they preferred to be contacted by telephone or mail and correct contact information was confirmed. The immunization champion nurse would then contact the patients up to 3 times when their next doses were due. It was not recorded how often the nurse would successfully contact the patient, or how many attempts at contact were made if fewer than 3.

      Study population

      Inclusion criteria were different for each immunization cohort. All women aged 15 years and older who made a visit to either clinic during influenza vaccination season (defined as August 1 through March 31)

      Centers for Disease Control and Prevention. Pregnant women and flu vaccination, Internet panel survey, United States, November 2014. Available at: http://www.cdc.gov/flu/fluvaxview/pregnant-women-nov2014.htm. Accessed Oct 16, 2015.

      were included in the influenza cohort regardless of pregnancy. Women who delivered an infant from June 6, 2010 to June 5, 2014 at Denver Health Hospital and had at least 1 prenatal visit in either clinic within 9 months preceding delivery were included in the Tdap cohort. The HPV outcome was assessed per visit rather than per patient. As such, each clinic visit by a nonpregnant woman aged 15–26 years was assessed and included in the HPV analysis as an eligible visit if the patient was lacking any of the 3 HPV vaccines in the series.

      Analytic methods

      The primary outcome of our evaluation was receipt of Tdap and influenza immunization per current ACOG guidelines and HPV vaccine per eligible visit. All data were obtained retrospectively through use of the internal data warehouse. Of note, race/ethnicity and language are collected at registration based on patient self-report. Since patients could contribute data to the analysis on multiple occasions (eg, visits and pregnancies), all analyses included generalized estimating equations (GEE) to account for the within-subject correlation of repeated measures within individual patients. Immunization receipt was the primary dependent variable. For each model, we explored 3 approaches: (1) constant rates over time for each study period with a shift (increase/decrease) at the time of the intervention initiation, (2) spline models with different slopes for each period and a common intercept at the time the intervention began, and (3) a combination of different slopes for each period, along with a shift at the time of intervention initiation, an approach found to be useful in other studies.
      • Ross S.E.
      • Radcliff T.A.
      • Leblanc W.G.
      • Dickinson L.M.
      • Libby A.M.
      • Nease Jr., D.E.
      Effects of health information exchange adoption on ambulatory testing rates.
      Using quasi-likelihood under the independence model criterion (QIC) scores, models were chosen based on best fit. The best-fitting model for Tdap was approach 1. The best-fitting model for HPV was approach 3.
      For Tdap, the primary outcome was modeled at the individual level as a function of the period (preintervention, intervention following recommendation 1, and intervention following recommendation 2) and sociodemographic covariates. For HPV, the primary outcome was modeled at the visit level as a function of time and intervention period (preintervention slope, shift at time of intervention, and postintervention slope). For influenza, the primary outcome was modeled at the individual level, comparing the preintervention to the intervention period while adjusting for the sociodemographic covariates. Models for HPV and Tdap were tested for nonzero slope during each intervention period, as well as for shifts in slope at times of recommendation changes. Subsequently, for HPV we assessed whether the intervention significantly changed vaccination rates both with and without changing the slope found in the linear trend; a change in rates without change in the slope indicates that the effect is based on a shift rather than a change in slope. The same analyses were performed for Tdap, but since there were 2 recommendation changes these analyses compared the preintervention period both with the period between recommendations and after the second recommendation. For both Tdap and HPV, models assessing change in rate based on a shift were chosen based on better fit according to QIC scores. Time, patient age, race/ethnicity, payer, and language were included as covariates in all analyses. Demographics for each vaccine cohort before and after the intervention were compared using χ2 or t test where appropriate. Significance was assessed at a P < .05 level. All analyses were performed using SAS Enterprise Guide software version 9.3 (SAS, Cary, NC).

      Results

      Study population

      A total of 12,717 unique women were included in the influenza cohort, for a total of 19,409 observations (10,231 before and 9,178 after the intervention); 2650 women in the Tdap cohort, contributing 2741 observations (1248 before and 1493 after the intervention); and 4869 women in the HPV cohort, contributing 12,443 observations (7966 before and 4477 after the intervention). Patient demographics both before and after the intervention are presented in Table 2. Our patients were largely Hispanic, English-speaking, and publicly insured. There were small differences in all demographics before and after the intervention, with an overall modest trend in increasing age and share of public insurance and a decreasing proportion of Hispanic ethnicity and Spanish-speaking patients.
      Table 2Demographics per vaccine cohort before and after the intervention
      CharacteristicInfluenzaTdapHPV
      Before (n = 8354)After (n = 7525)PBefore (n = 1244)After (n = 1466)PBefore (n = 3626)After (n = 2334)P
      Age29.6 ± 10.530.3 ± 10.4<.0127.4 ± 6.027.0 ± 6.3.0921.9 ± 2.922.5 ± 2.6<.01
      Race/ethnicity
       Hispanic5842 (69.9)5017 (66.7)1018 (81.8)1109 (75.7)2577 (71.1)1585 (67.9)
       White, non-Hispanic942 (11.3)917 (12.2)<.0192 (7.4)149 (10.2).01361 (10.0)233 (10.0).01
       Black1325 (15.9)1342 (17.8)87 (7.0)138 (9.4)605 (16.7)452 (19.4)
       Other245 (2.9)249 (3.3)47 (3.8)70 (4.8)83 (2.3)64 (2.7)
      Language
       English4964 (59.4)4797 (63.8)562 (45.2)803 (54.8)2494 (68.8)1658 (71.0)
       Spanish3223 (38.6)2552 (33.9)<.01654 (52.6)621 (42.4)<.011087 (30.0)644 (27.6).06
       Other167 (2.0)176 (2.3)28 (2.3)42 (2.9)45 (1.2)32 (1.4)
      Insurance
       Public5149 (61.6)4865 (64.6)757 (60.9)961 (65.6)2559 (71.7)1694 (72.6)
       Private273 (3.3.)338 (4.5)<.0141 (3.3)66 (4.5).01110 (3.0)108 (4.6).01
       None2932 (35.1)2322 (30.9)446 (35.9)439 (30.0)917 (25.3)532 (22.8)
      Data are presented as n (%) except age, presented as mean ± SD.
      n = total number of women in timeframe.
      HPV, human papillomavirus; Tdap, tetanus, diphtheria, and acellular pertussis.
      Mazzoni et al. Immunization in ob-gyn clinics. Am J Obstet Gynecol 2016.

      Influenza vaccination

      The rate of influenza vaccination increased from 35.4% in the 2 years prior to the intervention to 46.0% in the 2 years post-intervention. After controlling for age, race/ethnicity, and insurance in GEE regression models for Tdap and HPV, patients remained significantly more likely to have been vaccinated during the intervention period than before (P < .001).

      Tdap vaccination

      The Tdap models showed a shift in rates for each time period and roughly constant rates within each time period (approach 1). The overall raw average rate for up-to-date Tdap vaccination increased from 87.6% before the intervention period to 94.5% in the period after intervention until recommendation 2 was implemented. The monthly rate immediately following the implementation of recommendation 2 decreased to 50.7%. However, the monthly rates increased sharply over the subsequent 3 months, resulting in an average post–recommendation 2 rate of 75.0% (Figure 1). Compared to the preintervention period, adjusted overall rates were significantly higher following implementation of interventions (z = 4.58, P < .0001), and significantly lower following implementation of recommendation 2 (z = -5.77, P < .0001), controlling for age, language, race, and insurance status.
      Figure thumbnail gr1
      Figure 1Tdap vaccination rate by current ACOG recommendation
      Tetanus, diphtheria, and acellular pertussis (Tdap) vaccination rates increased following the intervention, then decreased following the recommendation for Tdap in every pregnancy.
      Mazzoni et al. Immunization in ob-gyn clinics. Am J Obstet Gynecol 2016.

      HPV vaccination

      HPV vaccination rates showed a change in linear trend (slope) along with a shift at the time of intervention (z = 22.12, P < .0001). The overall raw rate of HPV vaccination with an eligible visit increased from 7.1% before to 23.7% after the intervention. Slope was higher in the preintervention time period, leveling off somewhat (but at a higher overall rate) following the intervention (Figure 2). Stratified analyses showed an increase in rates for all categories of insurance: private (7.8% before and 19.3% after, P = .0155), public (6.5% before and 22.3% after, P < .0001), and uninsured (7.6% before and 24.3% after, P < .0001).
      Figure thumbnail gr2
      Figure 2HPV vaccination rate per eligible visit
      Rates of human papillomavirus (HPV) vaccination during eligible visits increased after the intervention.
      Mazzoni et al. Immunization in ob-gyn clinics. Am J Obstet Gynecol 2016.

      Comment

      Our multimodal intervention in urban underserved clinics resulted in a modest increase in immunization rates for each of the targeted vaccines. By implementing practices considered evidence-based in other settings, we demonstrated a positive effect in an outpatient ob-gyn population. While the interventions were created or adapted by research personnel in collaboration with clinic staff, there was a focus on sustainable practices for the institution and the actual implementation occurred by staff in a clinical setting.
      Most components of our multimodal intervention aimed to improve standard process and awareness of all vaccines for all patients regardless of pregnancy. We therefore included all patients in our influenza analysis, although we might have seen higher rates in our pregnant patients, given the focus on influenza vaccination in pregnancy. During the influenza season for which most recent national data are available (2012–2013), 41.5% of all adults were vaccinated. Hispanic adults had lower rates than all other races/ethnicities, at 33.8%.
      • Centers for Disease Control
      Flu vaccination coverage. 2013. Available at.
      Our institutional rate prior to the intervention was comparable to national rates for similar demographics, and while it increased post-intervention to slightly above national averages, the postintervention rates in the present study still remain well below the Healthy People 2020 goal of 70%.
      Healthy People 2020. Immunization and infectious diseases: IID-12.5.
      There are racial/ethnic and socioeconomic disparities for many vaccines, and this gap in coverage has recently widened for Tdap and HPV.
      Centers for Disease Control and Prevention. Noninfluenza vaccination coverage among adults – United States, 2012.
      In 2012 among women aged 19–26 years, blacks (29.1%), Hispanics (18.7%), and Asians (15.6%) had lower HPV coverage than that of whites (41.2%). Tdap coverage for black (9.8%) and Hispanic (8.7%) adults aged 19 and older was also lower compared with whites (16.1%). Given this disparity in a basic component of preventive care, the positive findings from our intervention in a predominately nonwhite population should be further appreciated.
      There was an initial increase in up-to-date Tdap vaccination rates following implementation of the intervention, and the overall decrease in up-to-date rates should be taken in the context of changing national recommendations during the study time period. National estimates for Tdap coverage among postpartum mothers are not available; however, coverage was 25.9% for those living with an infant younger than 1 year in 2012.
      Centers for Disease Control and Prevention. Noninfluenza vaccination coverage among adults – United States, 2012.
      Smaller regional published reports in postpartum mothers range from 59% to 72% coverage.
      • Healy C.M.
      • Rench M.A.
      • Castagnini L.A.
      • Baker C.J.
      Pertussis immunization in a high-risk postpartum population.
      • Yeh S.
      • Mink C.
      • Kim M.
      • Naylor S.
      • Zangwill K.M.
      • Allred N.J.
      Effectiveness of hospital-based postpartum procedures on pertussis vaccination among postpartum women.
      • Trick W.E.
      • Linn E.S.
      • Jones Z.
      • Caquelin C.
      • Kee R.
      • Morita J.Y.
      Using computer decision support to increase maternal postpartum tetanus, diphtheria, and acellular pertussis vaccination.
      • Housey M.
      • Zhang F.
      • Miller C.
      • et al.
      for Centers for Disease Control an d Prevention. Vaccination with tetanus, diphtheria, and acellular pertussis vaccine of pregnant women enrolled in Medicaid–Michigan, 2011-2013.
      Our Tdap vaccination rate for postpartum women during the preintervention period (87.6%) was already higher than these other reports. This is likely due to a pre-existing well-standardized process for the inpatient postpartum ward consisting of a standing order for Tdap at discharge from the hospital, if indicated. The change in recommendation to Tdap receipt during pregnancy occurred simultaneously with our intervention implementation. We hypothesize we would have seen an even further decline in vaccination rates per current guidelines were it not for the intervention; instead, after the sudden decline, up-to-date vaccination rates in this population were slightly increasing until the end of the study period. Robust data are lacking since the most recent ACIP pregnancy update; however, 2 authors have estimated that 2.6% and 14.3% of women received Tdap during a current pregnancy, as recommended.
      Centers for Disease Control and Prevention. Updated recommendations for use of tetanus toxoid reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women—Advisory Committee on Immunization Practices (ACIP), 2012.
      • Housey M.
      • Zhang F.
      • Miller C.
      • et al.
      for Centers for Disease Control an d Prevention. Vaccination with tetanus, diphtheria, and acellular pertussis vaccine of pregnant women enrolled in Medicaid–Michigan, 2011-2013.
      Our rate after recommendation for immunization in each pregnancy far exceeds those previously published. With this recommendation implementation, our institution saw a rapid and short-lived decline in vaccine receipt per ACOG guidelines, likely a result of a significant increase in the denominator as women became immediately eligible for the Tdap vaccine as a result of the recommendation change. However, the rate quickly increased again, which we largely attribute to the study interventions.
      With the exception of the reminder/recall program, strategies to increase HPV immunization were system-level changes aimed to increase the numbers of captured opportunities for vaccination. As such, our analysis for HPV vaccination trends was at the level of the visit to best assess those opportunities as missed or captured, and we do not report on overall coverage rates or initiation/completion of the series. In contrast, most national reports of adult HPV vaccination are patient-level coverage rates, thereby making comparisons with our findings difficult. In 2012, 34.5% of all US women aged 19–26 reported at least 1 dose of the vaccine.
      Centers for Disease Control and Prevention. Noninfluenza vaccination coverage among adults – United States, 2012.
      There are reports from pediatric adolescent settings in which HPV captured opportunity rates ranged from 18% to 37%, notably better than our postintervention rate in an adult clinic.
      • Wong C.A.
      • Taylor J.A.
      • Wright J.A.
      • Opel D.J.
      • Katzenellenbogen R.A.
      Missed opportunities for adolescent vaccination, 2006-2011.
      • Mayne S.L.
      • duRivage N.E.
      • Feemster K.A.
      • Localio A.R.
      • Grundmeier R.W.
      • Fiks A.G.
      Effect of decision support on missed opportunities for human papillomavirus vaccination.
      This difference likely results from 2 factors: vaccines are more routine in pediatric clinics than in adult clinics; and while the burden of HPV disease is seen by ob-gyns, the focus of HPV vaccination is young girls aged 11–12 years.
      We used interventions proven successful in pediatric and inpatient populations and translated these to our ob-gyn outpatient population. There are scant data on these same interventions in outpatient ob-gyn populations and we are aware of no other studies of these interventions in safety-net ob-gyn settings including both pregnant and nonpregnant women. One investigation of automated reminders for HPV in reproductive health centers did not increase vaccine series completion.
      • Patel A.
      • Stern L.
      • Unger Z.
      • Debevec E.
      • Roston A.
      • Hanover R.
      • et al.
      Staying on track: a cluster randomized controlled trial of automated reminders aimed at increasing human papillomavirus vaccine completion.
      In contrast, other reports of system-level changes, mostly involving standing orders and electronic decision support, have been shown to increase both influenza immunization in pregnant women and Tdap immunization for postpartum mothers.
      • Klatt T.E.
      • Hopp E.
      Effect of a best-practice alert on the rate of influenza vaccination of pregnant women.
      • Mouzoon M.E.
      • Munoz F.M.
      • Greisinger A.J.
      • et al.
      Improving influenza immunization in pregnant women and healthcare workers.
      • Healy C.M.
      • Rench M.A.
      • Castagnini L.A.
      • Baker C.J.
      Pertussis immunization in a high-risk postpartum population.
      • Yeh S.
      • Mink C.
      • Kim M.
      • Naylor S.
      • Zangwill K.M.
      • Allred N.J.
      Effectiveness of hospital-based postpartum procedures on pertussis vaccination among postpartum women.
      • Trick W.E.
      • Linn E.S.
      • Jones Z.
      • Caquelin C.
      • Kee R.
      • Morita J.Y.
      Using computer decision support to increase maternal postpartum tetanus, diphtheria, and acellular pertussis vaccination.
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      for Centers for Disease Control an d Prevention. Vaccination with tetanus, diphtheria, and acellular pertussis vaccine of pregnant women enrolled in Medicaid–Michigan, 2011-2013.
      As mentioned previously, we focused on system-level changes because individual patient-level interventions, such as text messages to pregnant women, have shown little to no effect in improving vaccination rates.
      • Stockwell M.S.
      • Westhoff C.
      • Kharbanda E.O.
      • et al.
      Influenza vaccine text message reminders for urban, low-income pregnant women: a randomized controlled trial.
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      • Hasley S.
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      Improving influenza vaccination rates in pregnancy through text messaging: a randomized controlled trial.
      There are limitations of our evaluation that should be considered. Underreporting may have occurred owing to lack of documentation in the EMR system; however, it is likely that the rates of underreporting are the same in the pre- and postintervention periods. Women may have received their vaccines elsewhere and not been captured in our internal reporting system. This also would equally impact both time periods and therefore not affect the change in rates reported. The interventions employed were successful in our large urban integrated health-care system and may not be suitable for all clinical settings. We were also not able to account for secular trends in vaccination rates, which may have impacted our results. Finally, our population is largely Hispanic and medically underserved, thereby limiting the generalizability of our results.
      There is an urgent need for improved immunization coverage of all adults. Integrating vaccines to routine obstetrics and gynecology practice would clearly impact many women and their families. We found that implementing evidence-based practices routinely used in other populations modestly improved the immunization rates in our ob-gyn population. Future public health programs should explore additional innovative approaches to increase immunization delivery in women’s health care.

      Acknowledgments

      The investigators thank Paulette Naranjo, BSN, RN and Kathie Chichester, BSN, RN of Denver Health and Hospital for their contribution to the immunization intervention.

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