A pharmacist-driven academic detailing program to increase adult pneumococcal vaccination

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Evaluation: Academically-detailed immunization providers received a six-question survey.
Pneumococcal disease rate differences between the study periods were evaluated with Fisher's exact tests, while changes in vaccination were assessed with chi-square tests.
Results: From November 2013 through July 2015, our academic detailers visited and/or distributed our vaccination pathway materials to over 400 practice sites across Rhode Island, including 68% of community pharmacies and all adult acute care hospitals.Of the 413 surveys completed, 92% of respondents agreed that their knowledge of the PCV13 and PPSV23 vaccines had improved.Pneumococcal vaccination increased significantly (absolute difference 3.9%, percent change in proportion 5.4%; p=0.01) and pneumococcal disease decreased significantly between the pre-intervention and intervention periods (-2.74/10,000 discharges, 95% confidence interval [CI] -5.15, -0.32; p=0.02).Invasive pneumococcal disease decreased by 21 cases per 1,000,000 population per year between the pre-intervention and post-intervention periods (95% CI -42.25, 0.14; p=0.05).

Conclusion:
Our statewide pharmacist-driven pneumococcal vaccination educational outreach program resulted in favorable provider feedback relative to knowledge change and perceptions.
Vaccination increased while pneumococcal disease decreased during the study period.

Background
• Pneumococcal vaccination remains well below the Healthy People 2020 goal of 90% in older adults, both nationally and in Rhode Island.
• Prior to the intervention, Rhode Island had a higher burden of invasive pneumococcal disease than the rates observed regionally or nationally.
• Pneumococcal vaccination recommendations have undergone several changes in recent years, including expanded indications for vaccination.

Findings
• Pharmacist-led academic detailing sessions improved self-reported immunization provider knowledge of PCV13 and PPVSV23 vaccination recommendations, resulting in intentions to apply this knowledge in clinical practice and expected changes in their vaccination practices.
• Since implementing our academic detailing and community outreach intervention in Rhode Island, (1) invasive pneumococcal disease decreased despite increases in New England during the same time period, (2) pneumococcal vaccination increased significantly, and (3)   there were significantly fewer pneumococcal disease hospital discharges.

Introduction
More than half of pneumococcal disease in older adults occurs in non-vaccinated patients who have an indication for pneumococcal vaccination. 1,2Moreover, an estimated 67 million at-risk individuals in the United States (US) have not yet been vaccinated. 1,2This data is extremely concerning because patients with Advisory Committee on Immunization Practices (ACIP) indications for pneumococcal vaccination are twice as likely to die as those without indications if they develop invasive pneumococcal disease. 3[13][14][15]

Objectives
We developed a statewide pharmacist-led, education campaign utilizing academic detailing and patient outreach to improve adult pneumococcal rates by increasing knowledge and awareness of pneumococcal immunization recommendations.To assess the effectiveness of our approach for improving pneumococcal vaccination in Rhode Island through education, we evaluated a range of outcomes, including changes in vaccination rates, invasive pneumococcal infections, and pneumococcal pneumonia, as well as provider feedback on academic detailing.

Setting
Our education campaign targeted immunization providers and residents of Rhode Island.
Immunization providers were educated in the practice setting, as well as at conferences and meetings.Patients were educated at community events and through radio announcements.

Decision pathway and educational materials
The pharmacist-led academic detailing team developed a vaccination pathway (i.e., clinical decision-support tool) designed to address the complex pneumococcal vaccine administration schedules and corresponding indications, which served as a central component for immunization provider education.2][13][14][15] After initial pathway development, local infectious disease specialists were asked to provide critical analysis and feedback to help ensure the final pathway provided complete information in an easy-to-follow format.When necessary, the pathway was updated to reflect the most current guideline recommendations.The vaccination pathway was reviewed and approved by the Rhode Island Department of Health and copyrighted by the University of Rhode Island Office of Intellectual Property and Economic Development.
The four-page pathway document was laminated and held together by a corner ring for durability and accessibility in the clinical setting.The pathway included the adult pneumococcal vaccination recommendations and schedule for both PPSV23 and PCV13, medical conditions requiring pneumococcal vaccination, facts about pneumococcal disease, frequently asked questions about pneumococcal vaccination, package insert information on both types of pneumococcal vaccinations, as well as contraindications, side effects, and precautions.Contact information for the major insurance carriers in Rhode Island was also provided.
A patient vaccination wallet card and pneumococcal vaccination patient information handout were also created.The wallet card included space to record vaccination status for multiple adult immunizations and important medical information.A wallet card sleeve was incorporated to protect the wallet card and included a reminder to "please carry this with you and show to your healthcare professional".The wallet card was approved by the Rhode Island Department of Health and the Ocean State Adult Immunization Coalition.An educational patient handout was developed and included information on the dangers of pneumococcal disease, who should be vaccinated, and prompted patients to contact their immunization providers to get vaccinated.The handout was developed using resources from the Immunization Action Coalition, the National Foundation for Infectious Diseases, and scholarly articles.The wallet card, wallet card sleeve, and patient handout were all printed in English and in the 5 most common foreign languages spoken in Rhode Island since 5.7% of households in Rhode Island are linguistically isolated.

Implementation, immunization providers
In an effort to introduce our vaccination pathway to immunization providers throughout the state, our team (Authors JMD, KEW, KO, KLL, Group [JPB, MLC, BF, VL], Acknowledgements [TJK, RM, NRD]) attended 22 events with pharmacist, physicians, and nurse attendees.Presentations All materials distributed during our statewide academic detailing and community outreach campaign were made available for download from the URI Drug Information Services website (http://web.uri.edu/pharmacy/drug-info/) to ensure continued access to the vaccination pathway and patient handouts and to make the materials available to a wider audience.An email with the link to the website was sent to approximately 50 immunization providers in the state.

Implementation, community pharmacies
A list of all CVS, Rite Aid, Target, and Walgreens pharmacies in Rhode Island was compiled.The To reach patients of diverse backgrounds throughout Rhode Island, the study team and the URI Pharmacy Outreach Program attended over 100 public health events over the intervention period.
Events included public health fairs, such as the Feed 1,000 Rhode Islanders event for two consecutive years, brown bag events, support groups, and educational programs held at senior centers, senior housing, and community centers.Wallet cards, patient handouts, and sticks of lip balm promoting pneumococcal vaccination were distributed to attendees.At several events, formal presentation about pneumococcal disease and pneumococcal vaccination were made to attendees.

Practice innovation
To our knowledge, this is the first statewide pharmacist-driven academic detailing and community outreach campaign to promote adult vaccination.Academic detailing is "university or noncommercial-based educational outreach which involves face-to-face education to prescribers by trained healthcare professionals". 16,17The goal of academic detailing is to provide education consistent with medical evidence and guidance documents. 16,17With the complexity of recommendations for pneumococcal vaccination, development of an easy-to-understand pathway and corresponding educational materials served as the backbone for our academic detailing efforts.Prior to pathway development, implementation of the ACIP recommendations was difficult due to a lack of public and provider knowledge, electronic medical record systems that did not automatically recommend the correct vaccine, and perceived and actual financial/reimbursement limitations, mainly from the primary payer for older adults, Medicare.

Immunization provider survey
After academic detailing sessions, each provider participant was requested to take an anonymous 6 question survey about the effectiveness of their detailing session (see Supplementary File).
Surveys were either submitted electronically via Survey Monkey on an iPad, or paper surveys were collected in a sealed envelope, depending on immunization provider preference.Domains of survey measurement included content understanding, educational material ease of use, satisfaction with the academic detailing session, confidence in applying the new knowledge in practice, and intention to utilize the pathway and change vaccination practices.Each question followed a 5-point Likert scale, from strongly disagree = 1 to strongly agree = 5.We assessed the percent agreeing with each question (5 = strongly agree, 4 = agree).Health profession and setting were collected in the survey and question responses were compared between groups using the chi-square or Fisher's exact tests as appropriate.

Vaccination
Pneumococcal vaccination was determined from the Behavioral Risk Factor Surveillance System (BRFSS), a national, cross-sectional survey which collects information about health behaviors, disease, and preventive services, such as vaccination. 6,18We evaluated the percentage of adult respondents 65 years and older who have ever had a pneumonia vaccination in Rhode Island and the US.Percent changes in the proportion of respondents answering "yes" to this question over the study period were assessed, as were absolute differences.Rhode Island BRFSS count data was obtained from the Rhode Island Department of Health, and US percentages were obtained from the Centers for Disease Control and Prevention BRFSS website.

Invasive pneumococcal disease, case reports
The goal of vaccination is to prevent morbidity and mortality, particularly invasive disease.As such, we assessed changes in invasive pneumococcal disease in Rhode Island.Invasive pneumococcal disease has been a reportable disease nationally since 2010. 19 Mortality Weekly Reports. 20Notifiable disease reports collected by individual states and territories are sent to the Centers for Disease Control and Prevention, which are then published as weekly disease rates and compiled into annual reports. 20Final reports and provisional reports were used to calculate cases per study period (final report for 2016 not expected until late 2017). 20pulation estimates, provided as estimates as of July 1 each year, were obtained from the United States Census Bureau. 21

Pneumococcal disease, hospital discharge data
We assessed pneumococcal disease from hospital discharge data collected by the Rhode Island Department of Health.Discharge data is captured from 5 teaching hospitals providing general acute care, 6 other general acute-care hospitals, 2 psychiatric teaching hospitals, and 1 rehabilitation hospital.International Classification of Disease, 9 th revision (ICD-9) diagnosis codes were used to identify pneumococcal disease: pneumonia 481, bacteremia 038.2, and meningitis 320.1.Due to the switch from ICD-9 to ICD-10, hospital discharge data was only available through September 2015.

Statistical analysis
Discharge rates per 10,000 discharges and per 10,000 bed days were calculated.Invasive disease was calculated per 1,000,000 population.Using OpenEpi, changes in vaccination (for Rhode Island), infection type, inpatient mortality, and pneumococcal disease rate differences between the study periods were evaluated with chi-square, Fisher's exact, or t-tests, as appropriate. 22nd/or detailing session to be confusing, complicated, or lacking information (18/73), such as "Difficult to follow and had to flip back and forth" and "I would like a better description on the 2 indications for Prevnar".Of those that found the material or session confusing, 72% were nurses.
Other respondents noted that they do not vaccinate (3%) or were already implementing the pneumococcal vaccination recommendations (4%).

Pneumococcal disease
After our pharmacist-led academic detailing program, annual rates of pneumococcal disease declined significantly by 2.8 per 10,000 discharges (Table 3; p=0.02).This resulted in 0.5 fewer bed days of care per 10,000 bed days (p=0.04).Rates of pneumococcal disease were largely driven by pneumococcal pneumonia over the entire study period (79.2%).Compared to the preintervention period, the proportion of pneumococcal disease discharges in Rhode Island with pneumococcal pneumonia decreased significantly in the intervention period (86.0%vs 75.5%; p=0.01), and the proportion with pneumococcal bacteremia increased (24.3% vs 33.6%; p=0.06).
Inpatient mortality was significantly lower in the intervention period compared to the preintervention period (8.8% vs 3.6%; p=0.03).
Before our academic detailing program began, the annual rate of invasive pneumococcal disease was higher in Rhode Island (72/1,000,000 persons) than in New England (47/1,000,000 persons) or the United States (53/1,000,000 persons), as shown in Table 4

Discussion
[25] Additionally, we observed significant decreases in pneumococcal disease.Though the decline in invasive pneumococcal disease was at the boundary of statistical significance (p=0.05),Rhode Island went from having nearly 20 more cases of invasive disease per year than the overall rate for the United States, to having a similar rate in the post-intervention period.Further, although there was a significant increase in cases of invasive pneumococcal disease in New England, we observed a decrease in Rhode Island.
According to a recent systematic review, most academic detailing interventions have generally targeted one specific provider type (40.0%physician, 33.7% pharmacist, 27.4% nurse), fewer studies have implemented a multifaceted approach targeting various providers (23.2%), and only about one third included community outreach (31.1%),. 26Further, more than half of studies only measured one outcome (56.6%), and a majority of those measured clinician behavior (91.5%). 26r intervention was multifaceted both in the intervention and measurement of outcomes.Few studies have evaluated the impact of academic detailing on adult vaccinations, and fewer assessed the impact on actual vaccination or diseases rates. 27,28One randomized controlled study to increase the use of preventive services found that academic detailing and peercomparison feedback to physicians was no more effective in increasing influenza and pneumococcal vaccination than educational reminders. 29However, academic detailing has been effective for other medication management initiatives. 30r statewide academic detailing efforts, along with the supporting pathway and educational materials, impacted immunization providers' perception of knowledge about pneumococcal vaccination.Our survey results demonstrated that the academic detailing efforts increased immunization providers' perceived ability to identify patients eligible for pneumococcal vaccination and many providers indicated that the new knowledge would be incorporated into their clinical practice.Provider survey results suggests the education through academic detailing with supporting materials was effective for immunization providers in community settings but that improvements could be made in regards to hospital and nurse education.
Pharmacists consistently noted the pneumococcal pathway materials assisted them and clarified questions they had regarding recommendations for which patient populations should receive the PPSV23 and PCV13 and the administration schedules.Individual 1-to-1 approaches were mainly implemented to reach as many pharmacists as possible in their practice settings.The academic detailers remarked on the difficulties in providing consistent academic detailing at community pharmacies.Academic detailing in this setting is often challenging because of constraints on the pharmacists' time to step away from the workflow and this is dependent on prescription volume as well as additional professional staffing at the pharmacy.A large group meeting of pharmacy managers proved to be an efficient forum, allowing pharmacists the time to adequately review the materials and pose questions of the detailer.

Limitations
First, national vaccination recommendations were updated over the study period and meant outdated materials were in circulation.When this occurred, academic detailing was repeated in community pharmacies, adding considerable time to the project and effort from the academic detailers.The vaccination pathway did include the URI Drug Information Services website so that immunization providers could access and download the most recent version of the pathway.
Second, to account for seasonal changes in pneumococcal disease, the study periods were divided by calendar year, so the intervention period included a 5 month wash-out period without active academic detailing or community outreach activities.Though academic detailing began in November 2013, few sessions were conducted due to the holidays.As immediate effects on statewide pneumococcal disease rates from these sessions were not expected, categorization by calendar year was considered appropriate.Additionally, due to the switch from International Classification of Diseases 9 th Edition to 10 th Edition in October 2015, the codes for pneumococcal disease changed, and pneumococcal hospital discharges from the last quarter of 2015 onward were not included as rate differences may have been artefactual.Therefore, the intervention period for pneumococcal hospital discharges ended in September 2015.Third, though community pharmacies received two academic detailing sessions, different pharmacists may have participated in the detailing sessions, and as such, we were not able to follow-up with immunization providers to determine use of the academic detailing material in the practice or whether the pathways changed their immunization practices.Fourth, we could not calculate a response rate for the academic detailing survey.These results may be limited by response bias, 22 since the exact number of attendees was not known for some academic detailing sessions, and some pharmacists may have received academic detailing on multiple occasions.Fifth, we attempted to collect vaccination data from several sources, other than BRFSS, however, we were not able to obtain these data.Lastly, we were not able to control for other factors that may have influenced vaccination practices over time, including vaccine advertisements or internal immunization provider policies to increase pneumococcal vaccination.

Conclusions
Our statewide pharmacist-driven campaign to increase adult pneumococcal vaccination through academic detailing to immunization providers and community outreach efforts resulted in increased self-reported provider knowledge regarding the pneumococcal vaccine.During the study period, we observed increases in vaccination and decreases in pneumococcal disease in Rhode Island.2. The educational material is easy to understand.
3. This academic detailing session was effective.
4. As a result of this education, I am confident that I can apply this knowledge in clinical practice.
5. As a result of this education, I intend to apply the vaccination pathway in my practice.
6.As a result of this education, I expect my vaccination practices to change.
Comments for specific questions.
Please use the space below to add overall comments about the academic detailing or educational materials.

Pneumococcal Vaccination Naive or Unknown History
on our vaccination pathway were made to the Rhode Island Department of Health Flu Task Force, Rhode Island Certified Diabetes Outpatient Educators, Ocean State Adult Immunization Coalition, Wellness Company Nurses Protocol Meeting, Seminar by the Sea Northeast Regional Continuing Education Conference for Pharmacists, Rhode Island Pharmacists Foundation, Coastal Medical of Rhode Island, Rhode Island Department of Health Nurses Conference, and Economic Burden of Vaccine Preventable Diseases in Rhode Island.Additionally, we mailed copies of our vaccination pathway to hospitals and clinics in both Rhode Island and surrounding states.Events and mailings were either planned based on outreach efforts by the project team or by request of the event host or facility.

URI
College of Pharmacy has full-time faculty, adjunct faculty, and preceptors with clinical practice sites in community pharmacies across the state.The College's relationships with these pharmacies enabled us to present our pneumococcal vaccination pathway and conduct academic detailing at 68% (121/177) of Rhode Island pharmacies from November 2013 through July 2015.The academic detailers included URI faculty, a community pharmacy resident, and a student pharmacist.Various academic detailing methods were used to reach as many immunization providers as possible in the state.A 1-to-1, face-to-face approach was utilized at all of the CVS, Rite Aid, and Target pharmacy sites visited.Sessions lasted approximately 15 minutes, and each participant was provided education on how to use the pneumococcal vaccination pathway, vaccination indications, and the recommended schedule of vaccination.Academic detailing for Walgreens pharmacies consisted of a 20-minute presentation at the Walgreens District meeting of 70 pharmacy managers.Academic detailing sessions also occurred during two Rite Aid district meetings (23 stores).Patient outreach To further improve communication and coordination between patients and their immunization providers, a Public Service Announcement (PSA) was developed in collaboration with the Rhode Island Department of Health and Ocean State Adult Immunization Coalition, which aired in English and Spanish on Rhode Island radio stations: "Do you have diabetes or asthma?Do you smoke?Are you over 65 years of age?If you answered yes to even one of these questions, you are at increased risk for bacterial pneumonia.Bacterial pneumonia is an infection of the lungs.It's a dangerous disease that could send you to the hospital.In some cases, it can even be deadly.The good news is that you can protect yourself.Ask your doctor or pharmacist about the vaccine that protects against bacterial pneumonia.Vaccination -it's your best defense.Sponsored by the University of Rhode Island College of Pharmacy and the Rhode Island Department of Health".Our target audience for the PSA was adults 65 years and older, and based on demographics provided by the advertising company, six radio stations were chosen.The PSA aired a total of 227 times in December 2014.
Invasive disease is confirmed by isolation of pneumococcus from blood, cerebrospinal fluid, pericardial fluid, pleural fluid, peritoneal fluid, joint fluid, or other normally sterile site.Due to seasonal variations in pneumococcal disease, calendar years were used to define the study periods.The preintervention period was January 1 through December 31, 2013, the intervention period was January 1, 2014 through December 31, 2015, and the post-intervention period was January 1 through December 31, 2016.Due to the use of calendar years, the intervention period included a 5 month wash-out period without active academic detailing or community outreach activities which concluded in July 2015.Changes were compared between the pre-intervention and intervention periods, and pre-intervention and post-intervention periods.We collected the number of cases of invasive disease from Notifiable Disease and Mortality Tables from Morbidity and While PCV13 is FDA-approved for persons > 50 years, the Advisory Committee on Immune Practices does not provide guidance for use in this population.with IMMUNE COMPROMISING CONDITIONS (see chart on back), OR ASPLENIA (including sickle cell anemia), CEREBROSPINAL FLUID LEAK, or COCHLEAR IMPLANT ADULTS ≥ 19 with UNDERLYING MEDICAL CONDITIONS (see chart on back) OR who SMOKE or live in a NURSING HOME * Minimum interval between sequential administration of PCV13 and PPSV23 is 8 weeks in immunocompromised patients.For Medicare reimbursement interval must be 11 full months.Please refer to page 4. † The ACIP (Advisory Committee on Immunization Practices) recommends only 1 dose of PPSV23 at age ≥65.Revaccination is not necessary.§ A second PPSV23 for patients with cerebrospinal fluid leak, or cochlear implant is not required.PPSV23=23-Valent Pneumococcal Polysaccharide Vaccine (Pneumovax ® 23) PCV13=13-Valent Pneumococcal Conjugate Vaccine (Prevnar 13 ® ) . While the annual rate of invasive pneumococcal disease increased significantly in New England over the study period (74/1,000,000 persons; rate difference 26.35, 95% CI 20.73, 31.98;p<0.0001), it decreased in both the United States (45/1,000,000 persons; rate difference -7.78, 95% CI -8.87, -6.70; p<0.0001) and Rhode Island (51/1,000,000 persons; rate difference -21.06, 95% CI -42.25, 0.14; p=0.05).Comparing rates in Rhode Island to those in the US overall, Rhode Island had more cases of invasive disease per year in the pre-intervention period (rate difference 19.47, 95% CI 3.22, 35.71; p=0.006).In the post-intervention period, the Rhode Island rate was similar to that of the US (rate difference 6.19, 95% CI -7.46, 19.84; p=0.34).

Table 1 .
Immunization provider survey of academic detailing, percent agreeing or strongly agreeing, by setting

Table 2 .
Immunization provider survey of academic detailing, percent agreeing or strongly

Table 3 .
Change in annual rates of pneumococcal disease hospital discharges, Rhode Island a Comparison of pre-intervention and intervention periods significantly different (p<0.05).

Table 4 .
Change in annual rates of invasive pneumococcal disease a Comparison of pre-intervention and post-intervention periods, p=0.05.b Comparison of pre-intervention and intervention periods significantly different (p<0.05).c Comparison of pre-intervention and post-intervention periods significantly different (p<0.05).