Cynthia M. Rand

Introduction: We evaluated the impact of a provider and nurse-based intervention on influenza and Tdap vaccination rates among pregnant women. Methods: The VAX-MOM trial was a 2-arm cluster randomized clinical trial conducted across 4 health systems (14 obstetric practices in Rochester, NY, and 13 in Los Angeles, CA), from April 2021 to June 2022. Practices were randomized to receive provider and nurse training via online modules (covering influenza and pertussis infections, vaccination, and workflow changes, such as presumptive vaccine recommendations) or standard care. Co-primary outcomes were influenza and Tdap vaccination rates for women delivering live births during the intervention. Analyses adjusted for clustering within practices. Results: The study included 5992 and 6768 women eligible for Tdap vaccination, and 4609 and 5294 women eligible for influenza vaccination (intervention and control practices, respectively). Influenza vaccination rates declined by 5% in the intervention group (57% to 52%) and by 10% in the control group (57% to 47%). Tdap vaccination rates increased by 3% in both groups (67% to 70% in intervention; 72% to 75% in control). Adjusted analyses showed influenza vaccination rates were 8% higher in intervention practices (aRR 1.08, 95% CI [1.00, 1.15], p = 0.038; not significant given the p < 0.025 cutoff for 2 outcomes). Tdap rates showed no significant difference. Post-hoc analysis excluding one minimally engaged system revealed influenza vaccination rates were 13% higher in intervention practices (aRR 1.13, 95% CI [1.06, 1.19], p < 0.001). Conclusion: Provider and nurse training improved influenza vaccination rates but did not significantly affect Tdap coverage in engaged practices.

Approximately two out of three children and one out of four adults experience significant anxiety related to vaccination, which can result in vaccine avoidance. Promoting patient autonomy by empowering individuals to choose coping strategies that work best for them can enhance the overall vaccination experience. The CARD system is an innovative, patient-centered approach that improves the vaccination experience for both patients and healthcare providers.

We conducted a quality improvement (QI) study to increase rates of firearm screening/safety counseling by 25% over 10 months for children (4-18 years) at preventive visits in an academic continuity clinic. Plan-Do-Study-Act (PDSA) cycles consisted of 1) (January 2023) educating providers about best practices for screening, safe storage counseling, and use of cable firearm locks; 2) (May 2023) revising the preventive visit note template to prompt providers on best practices; and 3) (September 2023) providing caregiver educational resources to support safe storage practices. The baseline firearm screening rate was 38%. After PDSA 1, screening rates were 34%; following PDSA 2, screening rates increased to 82.5%; after PDSA 3, rates were 95%. This QI intervention increased provider screening for firearms, confidence in safety counseling, and confidence in the use of cable firearm locks during preventive visits. Revising the note template had the largest effect on increasing screening rates.

Objectives Despite the seriousness of influenza and pertussis, availability of safe and effective vaccines against them, and long-standing maternal vaccination recommendations, US maternal influenza and Tdap vaccination rates have been low. To increase vaccination rates in obstetric offices, it is important to understand clinician perspectives and office processes. We conducted in-depth interviews with nurses and providers on these topics. Methods Interviewees worked in obstetric offices in one-of-four participating health systems in NY and CA. We audio-recorded and transcribed 20–30-min interviews. We used predetermined categories to code interviews with Dedoose, then iteratively refined codes and identified themes. Results We conducted 20 interviews between 4/2020 and 9/2020: 13 providers (physician or nurse midwife) (5 NY, 8 CA); 7 office nurses (6 NY, 1 CA). In almost all offices, patient refusal of influenza vaccine was considered the major vaccination barrier; Tdap was often deferred by patients until post-delivery. Nurse-only visits for either vaccine were rare. Vaccination outside the office was uncommon; few offices systematically documented vaccines given elsewhere in a retrievable manner. Participants emphasized patient education as key to prenatal care, but the number of topics left little time for immunizations. Few interviewees could identify an office “immunization champion,” knew their office vaccination rates, or had participated in vaccination quality improvement. Several interviewees indicated that they or another provider were good at persuading hesitant patients, but their method had not been shared with other clinicians. Conclusions for Practice Multiple practical barriers and maternal vaccine hesitancy limit maternal vaccination. Quality improvement strategies are needed.

Background: Although maternal vaccination with influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccines improve health outcomes for pregnant individuals and infants, maternal vaccination rates are low. This study assessed obstetric providers' attitudes and practices related to influenza and Tdap vaccination in four large health systems in New York (NY) and California (CA). Methods: We conducted a cross-sectional survey of all obstetric providers within four health systems (two in NY, two in CA) to evaluate provider attitudes and office systems used for Tdap and influenza vaccination. The survey assessed perceptions of influenza and Tdap vaccination based on the Health Belief Model, and assessed office systems (reminders, prompts, standing orders, and patient education) and communication with pregnant patients related to influenza and Tdap vaccines. Results: We had 112 responses (52% response rate) for analyses. Respondents strongly supported vaccination during pregnancy but viewed influenza disease as less of a concern for newborns than for pregnant individuals (40% vs. 67% considered influenza disease to be very significant, p < 0.001). Only 84% agreed that giving influenza vaccine in the first trimester is very safe. Patient vaccine refusal was the most commonly named barrier for both influenza and Tdap vaccination. Providers frequently used office system prompts, but did not frequently use standing orders, patient educational materials, vaccine champions, and feedback on vaccination rates. Conclusions: While most providers consider influenza and Tdap vaccination important during pregnancy, there is room for improvement in focusing on the importance of maternal vaccination to the health of the infant, and increasing the use of office systems to improve vaccination during pregnancy.

The objectives of this study were to assess the contextual factors, practice strategies, and sustainability of interventions implemented during a national quality improvement (QI) project to raise human papillomavirus (HPV) vaccination rates. We conducted semistructured interviews with positive deviant practices that successfully reduced missed opportunities by ≥20% for HPV vaccination in the prior year. We assessed leadership support, motivators, interventions used, and sustainability. Key themes related to QI teams included strong leadership support, multidisciplinary teams, having a practice champion, and a collaborative environment. Themes related to the interventions included using a presumptive bundled recommendation for all appropriate vaccines at age 11, previsit planning, and reminders for preventive visits, which were sustainable for most practices 1-year postintervention. Both internal practice-level factors (multidisciplinary teams, collaboration, and previsit planning) and organizational factors (institutional support and health system–level reminders for preventive visits) were key to a successful QI intervention to improve HPV vaccination.