SummaryKelsey-Seybold Clinic launched a multidimensional campaign, aimed at obstetricians and their office staff, to increase influenza immunizations in pregnant patients. Key elements include ensuring adequate vaccine supply and infrastructure, conducting periodic educational programs that emphasize the effectiveness and safety of vaccinating pregnant women, sharing clinic- and provider-specific data on immunization rates, empowering nurses to take the lead in providing immunizations, revising standing orders, and offering discounted fees. The program has led to a 26-fold increase in the immunization rate over a 10-year period, from 2.5 to 65.2 percent.
SModerate: The evidence consists of pre- and post-implementation comparisons of influenza vaccination rates among pregnant patients, with data gathered from a retrospective search of billing data in an electronic database.
Developing OrganizationsKelsey-Seybold Clinic
Date First Implemented2003
Patient PopulationThe program serves pregnant women cared for at Kelsey-Seybold Clinic.Gender > Female; Vulnerable Populations > Women
Problem AddressedBecause women who are pregnant face a higher risk of influenza-related respiratory illnesses than those who are not pregnant, government health organizations recommend that all pregnant women be immunized against influenza during the annual October to May flu season. Despite these recommendations and clear evidence that the vaccine can be administered safely throughout pregnancy, many obstetricians fail to immunize their pregnant patients.
- A major health threat to pregnant women: Influenza causes 36,000 deaths and approximately 226,000 hospitalizations annually in the United States.1 Pregnancy increases the health risks from influenza, with pregnant women experiencing higher rates of medical visits and hospitalizations for respiratory illnesses during influenza season than do women who are not pregnant.2
- Failure to immunize pregnant women, despite proven safety: Even though pregnant women and those planning to become pregnant can be safely immunized with an inactivated vaccine, many obstetricians do not promote use of the vaccine because they fear it is not safe for pregnant women or mistakenly believe it should be postponed until the second or third trimester. In 2005-2006, only 12.8 percent of pregnant women nationwide received the flu vaccine in the United States. At Kelsey-Seybold Clinic, influenza immunization rates were even lower, with only 2.5 percent of the clinic's pregnant patients being immunized between 1998 and 2003.3
Description of the Innovative ActivityKelsey-Seybold Clinic launched a multidimensional campaign, aimed at obstetricians and their office staff, to increase influenza immunizations in pregnant patients. Key elements include ensuring adequate vaccine supply and infrastructure, conducting periodic educational programs that emphasize the effectiveness and safety of vaccinating pregnant women, sharing clinic- and provider-specific data on immunization rates, empowering nurses to take the lead in providing immunizations, revising standing orders, and offering discounted fees. Details on each of these key elements appear below:
- Robust supplies and adequate infrastructure: As soon as the influenza vaccine becomes available in late summer or early fall, all Kelsey-Seybold Clinics—especially those serving pregnant women—receive robust supplies, thus ensuring adequate availability for all patients. Obstetricians have the space and equipment to store the vaccine, including a refrigerator, thermometers, and temperature logs. As a result, these obstetricians no longer need to refer pregnant patients to pharmacies or other providers (which reduces the odds that a patient will be immunized).
- Quarterly educational sessions and annual training: During quarterly meetings and when new information is released by Federal health agencies, obstetricians, nurses, and staff receive education highlighting the safety and effectiveness of immunizing pregnant (and other) patients. In addition, Kelsey-Seybold’s clinical education department sponsors an annual session on immunizations; nurses receive continuing education credits for attending the programs.
- Sharing of physician- and clinic-specific immunization rates: Using billing data, Kelsey-Seybold shares information with all providers on obstetrician- and clinic-specific annual immunization rates for all patients, including those who are pregnant. Historically, these data show significant variation across providers; for example, during 2008-2009, provider-specific immunization rates among 29 obstetricians ranged from 2.1 to 72.4 percent. Such feedback serves to stimulate improvement by encouraging friendly competition across providers and clinics.
- Nurses who take lead in immunizing patients: Some doctors empower their nurses to take the lead in immunizing patients as part of the initial screening and medical history-taking process for pregnant patients. Physicians who have delegated this task to a nurse generally have achieved higher vaccination rates than those who retain this responsibility.
- A champion who models appropriate behavior: The chief of the obstetrics and gynecology department serves as an "immunization champion," immunizing patients at every opportunity and encouraging nurses and obstetricians to do the same.
- Standing orders that call for immunization during pregnancy: The clinic revised its standing orders for influenza vaccine administration to specifically encourage all providers (obstetricians, primary care physicians, and nurses) to immunize pregnant patients. These standing orders are reviewed annually and revised as necessary.
- Discounts for patients with limited coverage: The flu vaccine, while recommended during pregnancy, is not covered under the bundled services payment received by obstetricians for pregnancy care. As a result, it is offered as a separately billed service. Some insurance plans require a higher copay for specialists, such as obstetricians, resulting in a copay that is greater than the cost of the vaccine. As a result, Kelsey-Seybold offers the vaccine within the bundle if possible, or as a primary care service resulting in a lower copay, or as a discounted fee-for-service item to reduce the patient’s out-of-pocket expenses.
Context of the InnovationKelsey-Seybold Clinic, a large multispecialty medical organization with more than 350 physicians and 2,100 employees, provides care to a racially and ethnically diverse population of more than 400,000 patients in 20 clinics in Houston, TX. The organization's obstetrics and gynecology department has 29 obstetricians who care for approximately 2,000 pregnant women and deliver approximately 2,500 infants annually at 5 Houston-area hospitals. The Kelsey Research Foundation develops and evaluates patient care and education programs; as part of this effort, the foundation maintains a database with obstetric information on more than 18,000 women and infants, thus allowing its researchers to examine maternal and infant outcomes. As part of this effort, the foundation’s obstetrical research committee, a collaboration between the foundation and The Woman’s Hospital of Texas (also in Houston), decided to implement this program as a way to improve the organization's low immunization rates among pregnant patients.
ResultsThe program led to a dramatic increase in vaccination rates among pregnant patients over a 10-year period. Between 1998 and the spring of 2003, only 2.3 percent of healthy pregnant patients treated by Kelsey-Seybold providers received an influenza vaccination. By 2011-2012, that figure jumped more than 26-fold, to 65.2 percent, with vaccination rates being equally high among healthy pregnant women and those with underlying conditions such as diabetes, heart disease, and cancer. During 2010, these providers immunized 47.2 percent of their pregnant patients against the H1N1 flu.
Moderate: The evidence consists of pre- and post-implementation comparisons of influenza vaccination rates among pregnant patients, with data gathered from a retrospective search of billing data in an electronic database.
Planning and Development ProcessKey steps in the planning and development process included the following:
- Appointing program champions: Program leaders identified and appointed a managing physician to take primary responsibility for increasing immunization rates among employees and patients and for formalizing policies in pediatrics and adult care clinics. They also identified a champion in the obstetrics and gynecology department who became actively involved in the work of the obstetrical research committee.
- Ensuring vaccine delivery system in place: Kelsey-Seybold established an immunization infrastructure, including the necessary equipment and protocols to order and maintain vaccine supplies, along with requisite billing and budgeting practices to monitor delivery of immunizations at each clinic location.
- Creating monitoring system: The Kelsey Research Foundation developed a system to provide timely data and analysis on immunization rates from the electronic medical record and billing systems.
Resources Used and Skills Needed
- Staffing: The program developer (the managing physician for immunization practices) spent approximately 40 hours establishing the initiative. Each year, a clinical committee consisting of the program developer, the chief pharmacist, an infection-control officer, the immunization-training nurse, and several others spends approximately 40 hours preparing Web-based educational materials, immunization logs, reports, and flyers to promote immunization of health care workers and patients, including pregnant women.
- Costs: The costs of the program are not available; major costs relate to researching, preparing, and printing Web-based educational information, holding training seminars, and mining electronic health and billing records to calculate and analyze immunization rates.
Funding SourcesKelsey-Seybold Clinic; Kelsey Research Foundation
The Kelsey Research Foundation funded the original study, including the management and reporting of data. The Kelsey-Seybold Clinic funds the program on an ongoing basis.
Tools and Other ResourcesFiore AE, Shay DK, Haber P, et al. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007. Atlanta, GA: Centers for Disease Control and Prevention, 2007. Morbidity and Mortality Weekly Report. MMWR Recomm Rep. 2007;56(RR06);1-54. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5606a1.htm.
Getting Started with This Innovation
- Educate providers with data: Because many physicians still believe that immunizations are not safe during the first trimester, share practice guidelines, study results, and agency recommendations (e.g., from the Centers for Disease Control and Prevention or the Advisory Committee on Immunization Practices) that demonstrate the safety of immunizations throughout pregnancy.
- Work with insurers to cover immunizations: Because vaccination for influenza is often not part of the covered bundle of services for pregnancy, introducing vaccinations may create an additional out-of-pocket cost for the patient, thus creating a potential barrier to immunization. To overcome this barrier, encourage insurers to cover immunizations by sharing data on their effectiveness and potential to reduce influenza-related illnesses. Providers can also develop options, such as providing discounts on the vaccine or billing the immunization as a primary care service to capitalize on the lower copay.
- Create infrastructure so obstetricians can stock vaccines: Many private obstetricians do not stock vaccines in their offices—they often lack refrigerators with adequate temperature controls, emergency power backup, and the protocols for appropriate use of thermometers and temperature logs. As a result, they may refer patients to pharmacies or other providers for an immunization, creating the potential that patients may not follow through on the referral (due to the extra time or the potential for additional costs, such as a required copayment). To overcome this issue, provide obstetricians with the requisite infrastructure to store adequate supplies.
Sustaining This Innovation
- Share provider-specific immunization rates: Providers often express surprise at their low immunization rates, especially compared with peers. Revealing these rates can be highly effective in changing behavior.
- Update vaccine recommendations annually: Because recommendations regarding who should be vaccinated can change markedly from year to year, providers need to be periodically educated about the latest guidelines.
- Consider standing order to immunize at first prenatal visit: Kelsey-Seybold leaders are considering changing their standing orders to encourage immunization during the first prenatal visit (if during flu season). They feel this approach will help ensure vaccination of all pregnant women by reducing variation in adherence across providers.
Contact the InnovatorMelanie Mouzoon, MD
Managing Physician for Immunization Practices
6624 Fannin Street, Suite 1900
Houston, TX 77030
Innovator DisclosuresDr. Mouzoon has not indicated whether she has financial interests or business or professional affiliations relevant to the work described in this profile.
References/Related ArticlesMouzoon ME, Munoz FM, Greisinger AJ, et al. Improving influenza immunization in pregnant women and healthcare workers. Am J Manag Care. 2010;16(3):209-16. [PubMed]
Fiore AE, Shay DK, Haber P, et al. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2007. Atlanta, GA: Centers for Disease Control and Prevention, 2007. Morbidity and Mortality Weekly Report. MMWR Recomm Rep. 2007;56(RR06);1-54. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5606a1.htm
Mouzoon ME, Munoz FM, Greisinger AJ. et al. Improving influenza immunization in pregnant women and healthcare workers. Am J Manag Care. 2010;16(3):209-16. [PubMed]
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Original publication: December 08, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: December 18, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: December 09, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.