Measuring Staff Influenza Vaccination Coverage in U.S. Hospitals Megan C. Lindley1, Juliet Yonek2, Faruque Ahmed1, Joseph F. Perz3, Gretchen W. Torres2,4 1 National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, GA 2 Health Research & Educational Trust, American Hospital Association, Chicago, IL 3 National Center for Preparedness, Detection and Control of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 4 Harris School of Public Policy Studies, University of Chicago, Chicago, IL

Disclosure Information The authors have no financial or other conflicts of interest to disclose The findings and conclusions in this presentation have not been formally disseminated by CDC and should not be construed to represent any agency determination or policy

Background Healthcare personnel (HCP) can serve as vectors for influenza transmission Share exposures with patients and community Influenza vaccination of HCP can reduce patient morbidity and lost work for HCP However, HCP influenza vaccination remains suboptimal (~45% in 2007)

Background (2) ACIP and HICPAC recommend annual influenza vaccination for all HCP Paid and unpaid; potential exposure Joint Commission standard (1/2007) Measure staff influenza vaccination National Quality Forum (NQF) developed harmonized vaccination measures CDC-sponsored measure of HCP influenza coverage received time-limited endorsement National Quality Forum (NQF), national voluntary consensus standards. Time limited endorsement “pending further study”

Objective Characterize practices related to measuring staff influenza vaccination rates in U.S. hospitals in the 2005-06 influenza season

Methods: Sample Selection Non-federal, short-stay, general medical, surgical, or children’s hospitals in 2004 AHA Annual Survey Database (N=4,621) Hospitals stratified by region and size Region: Northeast, Midwest, South, Pacific Size: <100 beds, 100-300 beds, >300 beds Stratified random sample of 996 hospitals Self-administered electronic survey of infection control coordinators in July 2006

Methods: Data Collection Hospital characteristics (AHA) Region, bed size, ownership, teaching status, urban/rural Influenza vaccine provision Cost, onsite, which staff groups, annual vaccination plan, activities in plan Tracking/reporting How tracked, data from staff not vaccinated onsite, develop reports, Measuring Coverage measurement(s), which employees included in rates Say three ways first, then detail briefly. Tracking vs. measuring

Methods: Staff Groups Direct employees: staff on hospital payroll having contact with patients or patient care items or areas Credentialed medical staff: attending/admitting physicians or independent practitioners not on hospital payroll Contract staff: contracted to work individually or through agency, not on hospital payroll Students/trainees, medical residents Volunteers

Methods: Analysis Weighting to account for sampling design and non-response Outcome: measuring influenza vaccination rate among hospital staff (yes/no) Descriptive statistics & bivariate associations Hospital characteristics, vaccine provision, tracking, and measurement Logistic regression w/ backward elimination Interaction term for size and region

Results - Respondents 555 of 996 hospitals (55.7%) responded Limited to 544 providing vaccine onsite 99.4% provide free of charge Southern or Pacific and for-profit hospitals less likely to respond (p<0.001) After weighting, responding hospitals were similar to all eligible hospitals Region, size, ownership, teaching status, urban

Results – Vaccine Provision, 2005-06 Plan for annual staff influenza vaccination 95.4% Written into policy 72.6% Measuring staff coverage 59.9% Internal reporting 65.0% Vaccine provided to: Direct employees 100.0% Credential medical staff 93.9% Contract staff 83.1% Students/residents 57.8% Volunteers 85.6% Strength of vaccination recommendation Require/strongly encourage 56.3% Recommends 25.8% Does not specify 17.9% Note most responses were not mutually exclusive so categories add to greater than 100%

Results – Tracking Vaccination, 2005-06 Hospital tracks onsite vaccination: 91.7% By staff overall 96.4% Type of staff 48.3% Department or unit 53.5% Information collected from unvaccinated staff: VIS if vaccinated offsite 19.3% Signed declination form 16.1% Medical forms from contraindicated staff 18.7%

Results –Measuring Coverage, 2005-06 Hospital measures staff vaccination coverage: 68.5% One rate for hospital 88.3% By staff type 20.0% Unvaccinated persons included in coverage rate: Contraindicated 43.5% Refused vaccination 50.6%

Staff Included in Coverage Rates

Results – Bivariate Analysis Hospitals measuring staff influenza vaccination coverage (68.5%): For profit > public or not for profit 100 or more beds > 0-99 beds South < Northeast, Midwest, Pacific Policy recommends or requires vaccination > does not specify Vaccination plan: Written into hospital policy Addresses data collection on vaccination Addresses internal reporting of coverage

Results – Logistic Regression Final model adjusts for geographic region and size Vaccination plan written into policy (OR 2.0, 95% CI 1.22-7.67) Plan addresses internal coverage reports (OR 4.8, 95% CI 2.97-7.66) Ownership, recommendation for staff vaccination, data collection and interaction term n.s.

Discussion Nearly 1/3 of hospitals did not measure staff influenza coverage in 2005-06 season Hospitals measuring coverage: May be unable to identify susceptible staff Most do not calculate rates by staff type Many do not track contraindications or refusals May not know true coverage rate among staff Various non-employees omitted from rates despite patient contact Most do not gather data on external vaccination

NQF-Endorsed Coverage Measure* Derived from 2006 ACIP/HICPAC recommendations Numerator: Vaccinees on and offsite Contraindicated and refusing measured separately Denominator: All HCP, paid or unpaid Standardized measure allows coverage to be compared across different facilities and providers Measuring contraindicated / refusing staff helps identify educational needs *www.qualityforum.org/pdf/reports/Immunization/Immunizations_Nonmembers.pdf

Limitations Respondents may not be representative of all eligible hospitals Weighting reduces but does not eliminate bias Did not validate self-reported data Difficult interpretation of contraindication/refusal question Cross-sectional survey cannot determine causality

Conclusions Substantial variation in measurement highlights need for standardized measures Evaluate feasibility and utility of NQF measure in different types of healthcare facilities Impact of Joint Commission standards Not all staff types covered Successful coverage measures will allow facilities to identify under-immunized HCP groups and target appropriate interventions Individual approach may encourage vaccination

National Center for Immunization and Respiratory Diseases Questions? Megan C. Lindley National Center for Immunization and Respiratory Diseases MLindley@cdc.gov

Eligible Hospital % (N) Respondent % (n) Eligible Hospital % (N) Region Northeast 13.4 (88) 13.4 (621) Midwest 29.5 (193) 29.4 (1,358) South 38.6 (189) 38.5 (1,777) Pacific 18.7 (85) 18.7 (865) Urban status Rural 44.2 (247) 43.2 (1,995) Urban 55.8 (308) 56.8 (2,626) Ownership Not for profit 61.7 (364) 61.1 (2,825) Private for profit 14.7 (62) 15.0 (694) Public 23.6 (129) 23.8 (1,102) Bed size < 100 46.6 (257) 46.5 (2,148) ≥ 100 53.4 (298) 53.5 (2,473) Teaching Yes 15.0 (88) 16.9 (780) No 85.0 (467) 83.1 (3,841)