BACKGROUND/RATIONALE:
Research has found that persons with SCI who contracted influenza or pneumonia were 37 times more likely to die from influenza or pneumonia than comparable individuals from the general population. Pneumonia is often cited as the primary cause of death during chronic SCI. Prevention of influenza and pneumonia and their subsequent complications through immunization is key. Unfortunately, vaccination rates for veterans with SCI&D have been unacceptably low in the past (<27% in 1998), although more recently there is evidence to suggest that rates have improved somewhat.

OBJECTIVE(S):
The study objectives are to: 1) increase the proportion of veterans with SCI&D who receive influenza and pneumococal pneumonia vaccinations; 2) increase staff awareness of the importance of vaccination; 3) increase the proportion of SCI staff that are vaccinated to help protect themselves and their patients; and 4) to decrease respiratory complications resulting in outpatient clinic and inpatient hospital use.

METHODS:
A multiple strategy approach was implemented to target patients, providers and the VA health care system. System strategies include standing orders and computerized clinical reminders. Patients received personalized mailed reminders and educational materials. Practitioners received educational materials and reminders both to vaccinate and educate their patients as well as to receive an annual flu shot themselves. These interventions were made available to all 23 VA SCI Centers. The proportion of veterans with SCI&D vaccinated against influenza and pneumococcal pneumonia will be assessed using mailed patient surveys with telephone follow-up as well as medical chart reviews as part of the VA’s External Peer Review Program (EPRP). Respiratory-related morbidity and mortality will be determined using VA administrative databases. Self-report surveys will be used to assess rates of annual influenza vaccinations among contact staff at SCI Centers. The costs of the intervention compared to the savings from the reduction of vaccine-preventable diseases and their complications will be estimated using VA administrative data. Finally, acceptance of the system changes will be gauged by monitoring the 23 centers in a series of telephone assessments throughout the project.

FINDINGS/RESULTS:
There has been a steady increase in vaccination rates in veterans with SCI. In year 1, 62% of veterans with SCI received the influenza vaccine, while in year 2, this increased to 68%. Data from year 3 indicate that influenza vaccination rates are now 79%. Similarly for PPV, the rates were 60% in year 1 and 75% in year 2. Year 3 data indicate a PPV rate of 82%. Patient factors were significant predictors of vaccination including older age, non-smoker, prior inrluenza illness, having seen a VA provider in the past year, and rating vaccination as important. Year 4 influenza vaccination data were collected to assess the impact of the national vaccination shortage. Rates dropped slightly to 72% for influenza vaccination. This was much better than the general population.

IMPACT:
This interventions appear effective and sustainable. System changes have been implemented. These efforts should be sustained with minimial addition effort or cost.

---

External Links for this Project

---

PUBLICATIONS:

Journal Articles

1. Weaver FM, Hatzakis M, Evans CT, Smith B, LaVela SL, Wallace C, Legro MW, Goldstein B. A comparison of multiple data sources to identify vaccinations for veterans with spinal cord injuries and disorders. Journal of the American Medical Informatics Association : JAMIA. 2004 Sep 1; 11(5):377-9. [view]
2. Evans CT, Lavela SL, Smith B, Miskevics S, Weaver FM, Goldstein B. Influenza diagnosis and treatment in veterans with spinal cord injury. Archives of physical medicine and rehabilitation. 2006 Feb 1; 87(2):291-3. [view]
3. Weaver FM, Smith B, LaVela S, Wallace C, Evans CT, Hammond M, Goldstein B. Interventions to increase influenza vaccination rates in veterans with spinal cord injuries and disorders. The journal of spinal cord medicine. 2007 Jan 1; 30(1):10-9. [view]
4. Weaver FM, Smith B, Evans CT, Kurichi JE, Patel N, Kapur VK, Burns SP. Outcomes of outpatient visits for acute respiratory illness in veterans with spinal cord injuries and disorders. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 2006 Sep 1; 85(9):718-26. [view]
5. Ullrich PM, Jensen MP, Loeser JD, Cardenas DD, Weaver FM. Pain among veterans with spinal cord injury. Journal of rehabilitation research and development. 2008 Jan 1; 45(6):793-800. [view]
6. LaVela SL, Smith BM, Weaver FM. Perceived Risk for Influenza in Veterans with Spinal Cord Injuries and Disorders. Rehabilitation Psychology. 2007 Nov 1; 52(4):458-462. [view]
7. Evans CT, LaVela SL, Smith B, Wallace C, Goldstein B, Weaver FM. Response to the 2004-2005 influenza vaccine shortage in veterans with spinal cord injuries and disorders and their providers. The journal of spinal cord medicine. 2007 Jan 1; 30(1):20-6. [view]
8. LaVela SL, Legro MW, Weaver FM, Smith B. Staff influenza vaccination: lessons learned. SCI nursing : a publication of the American Association of Spinal Cord Injury Nurses. 2004 Jul 1; 21(3):153-7. [view]
9. Stetler CB, Legro MW, Wallace CM, Bowman C, Guihan M, Hagedorn H, Kimmel B, Sharp ND, Smith JL. The role of formative evaluation in implementation research and the QUERI experience. Journal of general internal medicine. 2006 Feb 1; 21 Suppl 2:S1-8. [view]

Conference Presentations

1. LaVela SL, Legro MW, Weaver FM, Goldstein B, Smith B. Do Patient Intentions Predict Vaccination Behavior Over Time. Paper presented at: AcademyHealth Annual Research Meeting; 2004 Jun 1; San Diego, CA. [view]
2. Wallace C. Evaluating Facilitation Activities in a VA QUERI Implementation Project. Poster session presented at: AcademyHealth Annual Research Meeting; 2006 Jun 26; Seattle, WA. [view]
3. Weaver FM, Goldstein B, Legro M. Increasing influenza and pneumococcal pneumonia vaccinations in VA SCI&D. Paper presented at: American Paraplegia Society Annual Meeting; 2003 Sep 1; Las Vegas, NV. [view]
4. LaVela SL, Weaver FM, Smith B. Influenza Vaccination Rates in VA SCI Health Care Workers. Paper presented at: VA HSR&D National Meeting; 2003 Feb 1; Washington, DC. [view]
5. LaVela SL, Smith B, Weaver FM. Influenza Vaccination Rates in VA SCI Health Care Workers. Paper presented at: American Spinal Injury Association Annual Meeting; 2003 Apr 1; Miami, FL. [view]
6. Weaver FM, Goldstein B, Legro M. National Vaccine Project: Increasing Influenza and Pneumococcal Pneumonia Vaccinations in VA SCI. Paper presented at: American Paraplegia Society Annual Meeting; 2003 Sep 1; Las Vegas, NV. [view]
7. Evans CT, LaVela SL, Smith BM, Weaver FM, Goldstein B, Wallace C. Response to the 2004-2005 influenza vaccine shortage in veterans with spinal cord injury & disorder and their providers. Poster session presented at: Society for Healthcare Epidemiology of America Scientific Annual Meeting; 2006 Mar 1; Chicago, IL. [view]
8. Goldstein B. The National Vaccine Project: Increasing influenza vaccination rates in persons with SCI&D. Paper presented at: VA QUERI National Meeting; 2002 Dec 2; Washington. [view]
9. Smith B, Weaver FM, LaVela SL, Legro M, Wallace C, Evans CT, Goldstein B, Hammond M. The Use of Multilevel Modeling in Implementation Research: An Example from the SCI QUERI Initiative to Increase Respiratory Vaccinations. Poster session presented at: VA HSR&D National Meeting; 2005 Feb 1; Baltimore, MD. [view]
10. Weaver FM, Goldstein B, LaVela SL, Wallace C, Smith B, Legro M, Evans CT, Hammond M. Two Years of QUERI Intervention: Have Respiratory Vaccinations for Veterans with SCI Improved? Paper presented at: VA HSR&D National Meeting; 2005 Feb 1; Baltimore, MD. [view]
11. Wallace C, Legro M, Hatzakis M, LaVela S, Evans C, Weaver FM. Using Qualitative and Facilitation Methods to Implement and Evaluate Quality Improvement Interventions in VA Spinal Cord Injury Centers. Paper presented at: Agency for Healthcare Research and Quality Translating Research Into Practice and Policy Annual Meeting; 2003 Jul 1; Washington, DC. [view]
12. Legro M, Weaver FM, Goldstein B. VA Quality Enhancement Research Initiative (QUERI) Translation Project: Respiratory Vaccines for Veterans with Spinal Cord Injury and Disease (SCI&D). Paper presented at: AcademyHealth Annual Research Meeting; 2003 Jun 1; Nashville, TN. [view]
13. LaVela SL, Goldstein B, Smith B, Evans CT, Weaver FM. Working with Symptoms of a Respiratory Infection: Staff Who Care for High-risk Individuals. Poster session presented at: Society for Healthcare Epidemiology of America Scientific Annual Meeting; 2006 Mar 1; Chicago, IL. [view]

DRA: Health Systems
DRE: none
Keywords: none
MeSH Terms: Evidence-Based Medicine, Spinal Cord Injuries, Immunization Programs, Prevention