1. 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

2. 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

3. 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)

4. 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”

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

6. 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, beds, >300 beds
Stratified random sample of 996 hospitals
Self-administered electronic survey of infection control coordinators in July 2006

7. 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

8. 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

9. 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

10. 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

11. 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%

12. 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%

13. 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%

14. Staff Included in Coverage Rates

15. 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

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

17. Discussion
Nearly 1/3 of hospitals did not measure staff influenza coverage in 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

18. 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 *

19. 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

20. 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

21. National Center for Immunization and Respiratory Diseases
Questions?
Megan C. Lindley
National Center for Immunization and Respiratory Diseases

22. 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)