Influenza Vaccination in a High-risk Population: An Evidence-Based Approach to Public Health Practice Open Access

Bond, T. Christopher (2010)

Permanent URL: https://etd.library.emory.edu/concern/etds/2f75r834n?locale=en
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Abstract

Abstract
Influenza Vaccination in a High-risk Population:
An Evidence-Based Approach to Public Health Practice
By T. Christopher Bond

The vaccination of high-risk patients against influenza and other vaccine-preventable diseases is a public health priority. Evidence-based guidelines about how best to increase vaccination rates among high-risk patients are currently lacking or inconclusive. This dissertation reports the results of a multiyear plan to increase influenza immunization rates among patients with end-stage renal disease (ESRD) in 3 dialysis Networks (65,000 patients in 14 states).

The first study determined that the adoption of a controversially broad policy for vaccination ordering (facility-wide standing orders) may not be necessary. A provider survey and multivariable analysis of vaccination data showed that two policy options (chart orders and facility-wide orders) were equivalent in their associations with immunization against three vaccine-preventable diseases.

In a direct effort to increase influenza vaccination at poorly-performing centers, we developed a protocol for a multifaceted intensive intervention within a group-randomized evaluation. This design allowed us to isolate the marginal benefit that the "intensive" elements provided and controlled for the high year-to-year variability among these centers. The results showed that the effect of the intensive intervention was significant (+8.9%), but not as powerful as had been previously estimated.

A third study provided an estimate of the increased mortality risk associated with failure to receive influenza vaccination among ESRD patients using newly-available data on recent patient health status. The adjusted odds ratio for 1-year all-cause mortality was 0.83 (95% CI: 0.76, 0.91) for vaccinated versus unvaccinated patients.

Influenza Vaccination in a High-risk Population:
An Evidence-Based Approach to Public Health Practice
By
T. Christopher Bond
B.A., La Salle University, 1991
M.A., University of Notre Dame, 1995
Ph.D., University of Notre Dame, 1998
Advisor: William M. McClellan, M.D., M.P.H.
A dissertation submitted to the Faculty of the
James T. Laney School of Graduate Studies of Emory University
in partial fulfillment of the requirements for the degree of
Doctor of Philosophy
in Epidemiology
2010

Table of Contents

CHAPTER 1: INTRODUCTION............................................................... 1

The VPBA Survey: Association of Standing Order Policies with.....................4
Vaccination Rates in Dialysis Clinics
Assessment of an Intensive Intervention to Increase Influenza....................5
Immunization Rates
Multilevel Analysis of Influenza Vaccination and Mortality............................6
CHAPTER 2: LITERATURE REVIEW .......................................................8
Evidence-Based Public Health................................................................8
Assessing Health Status and Risk..........................................................10
Assessing Attitudes and Beliefs.............................................................13
Evidence Basis for Vaccination Policies and Practices................................17
Evaluating Public Health Interventions....................................................20
Measuring Impact of Implementation on Patients......................................22
CHAPTER 3: METHODS....................................................................... 24
Data Sources And Collection................................................................ 33
Specific Aims and Data Sources Used.....................................................38
CHAPTER 4: MANUSCRIPT 1................................................................ 40
Association of Standing Order Policies with Vaccination Rates in Dialysis
Clinics: A U.S.-Based Cross-Sectional Study
CHAPTER 5: MANUSCRIPT 2................................................................ 66
Improving Influenza Immunization Rates Among ESRD Clinics: a Group-
Randomized Evaluation of a Quality Improvement Intervention
CHAPTER 6: MANUSCRIPT 3................................................................. 90
Influenza Vaccination Status and Mortality in End-Stage Renal Disease
Patients
CHAPTER 7: CONCLUSIONS................................................................ 118

The VBPA Survey: Association of Standing Order Policies with
Vaccination Rates in Dialysis Clinics.........................................................118
Assessment of an Intensive Intervention to Increase Influenza
Immunization Rates..............................................................................120
Multilevel Analysis of Influenza Vaccination and Mortality............................124
Recommendations................................................................................126
Future Considerations...........................................................................127
REFERENCES.....................................................................................130
APPENDICES
APPENDIX A: ESRD Medical Evidence Report: Medicare Entitlement and/or Patient Registration (CMS-2728)
APPENDIX B: ESRD Death Notification (CMS-2746)
APPENDIX C: ESRD Facility Survey (CMS-2744A)
APPENDIX D: STIC Dialysis Facility Provider Immunization Survey: Practices, Beliefs, And Attitudes
APPENDIX E: STIC Immunization Data Collection Tool
APPENDIX F: STIC 2006-07 Influenza Immunization Worksheet
APPENDIX G: STIC Immunizations Quality Improvement Plan Development
APPENDIX H: STIC Quality Improvement Plan Data Collection Form

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