Health facility and service population description
WRSU is a rural, 40-bed IHS hospital and outpatient facilities complex on the White Mountain Apache Tribe Fort Apache Indian Reservation in eastern Arizona, with a user population of >16,000 people. Health services are provided to AIANs through IHS at no charge to the individual. The hospital provides adult and pediatric inpatient care, a birthing center and obstetric services, ambulatory surgery, and multiple support services. Outpatient services include a hospital-based clinic; an emergency department and urgent care services; a satellite clinic; and dental, optometry, physical therapy, pharmacy, and other support services.
The primary care staff at WRSU includes 20 physicians and eight nurse practitioners or physician assistants, representing 25 full-time equivalent clinical providers. There are approximately 1,500 WRSU hospital admissions, 1,200 transfers to other facilities, and 162,000 medical staff provider and nursing visits at WRSU annually. More than 96% of ambulatory visits are from Apache, Navajo, or Hopi tribal members.
Pneumococcal Vaccination Grant Project and Maintenance Program
In 2001, WRSU was awarded an IHS grant to fund a pilot site project to improve GPRA measures. One measure was the GPRA indicator for pneumococcal vaccination among adults with diabetes and people aged 55 years and older. The intent of the project was to improve the quality of vaccination records and to increase the PPV coverage of people with diabetes and adults ≥55 years of age. The ≥55 age category was chosen because a study on the White Mountain Apache Tribe Fort Apache Indian Reservation revealed higher IPD rates than other populations6
and this age category could be vaccinated with the resources available for the project. Vaccinations, previously recorded on paper (“hard copy” records) with subsequent electronic data entry into the electronic database, were updated so that all pneumococcal vaccinations for people with diabetes and people ≥55 years of age had an accurate electronic vaccination record. Vaccinations were administered at residents' homes, nine reservation work sites, and an elderly nutrition site by project nurses and during inpatient and outpatient visits by WRSU staff.
Following the vaccination project, the WRSU PPV vaccination program has been similar year to year, subject to modifications based on previous years' experience and advancements in the WRSU electronic health record (EHR). Vaccinations took place within WRSU facilities but generally were no longer administered in the field or at people's homes, as community vaccinations were an outreach provision through the vaccine project but not part of the vaccination program. WRSU adopted an informal (unwritten) policy following the project to vaccinate all AIANs ≥50 years of age due to the high rates of IPD in the WRSU population, and all people with high-risk conditions for IPD in accordance with Advisory Committee on Immunization Practices (ACIP) recommendations.14
This policy was formally adopted and placed on written and electronic reminders in 2006.
The EHR features a reminder tab that displays health maintenance recommendations, including vaccinations. However, diabetes was the only high-risk condition other than age among electronic reminders, as reminders are developed and upgraded through database software nationally and field facilities may only designate age groups and reminders for those with diabetes but not other high-risk conditions. At WRSU, the age-group reminder was set at age 50 and reminders for people with diabetes remained active. Vaccination reminders were also present on a paper health summary in hard copy charts. After the vaccination project was initiated in 2001, all vaccinations were documented electronically, which automatically updated health summaries in both hard copy health records and the EHR so that patients' vaccination status was subsequently immediately available throughout the service unit. A diabetes department, in operation before the vaccination project, continued to vaccinate people with diabetes through nurse educator visits and diabetes case management.
Changes since 2000 include PPV administered in patient examination rooms and during nursing screening instead of exclusively in a separate treatment room; initiation of an injection room for the specific purpose of providing injections, including vaccinations, to people without a primary provider appointment; primary care team dialysis center visits, which resulted in vaccination status documentation and referral of those not yet vaccinated; and PPV refusal documentation in patients' medical records. EHR visit documentation began with outpatient clinics in 2005 and was later extended to inpatient care in 2007; exceptions included emergency, urgent, and obstetrics inpatient and labor evaluation care not yet transitioned to the EHR.
Standing orders, reminders on patients' health summaries within paper medical records, and electronic reminders in the EHR permitted nurses to identify people in targeted groups and to vaccinate them immediately. Unvaccinated patients in targeted groups seen by medical providers were counseled and vaccinated in all outpatient and inpatient settings. Hospitalized patients often received vaccination immediately prior to discharge. All health care, including PPV administration within WRSU, was provided to AIANs without charge.
Revaccination is recommended by ACIP to people ≥65 years of age who received vaccine at least five years previously and were aged <65 years at the time of vaccination, and for immunocompromised people if at least five years have elapsed since receipt of first dose.
Health staff and public information
Pneumococcal vaccine recommendations and information were provided to WRSU clinicians using verbal communications and e-mails that promoted education and vaccination, and policies were placed in policy notebooks and electronically on the WRSU server. Formal policy referenced ACIP recommendations for PPV indications.14
Selected WRSU nurses attended two-day annual statewide immunization workshops that addressed pneumococcal vaccination among other immunizations. A vaccine information statement15
was provided to all people interested in or receiving vaccination, and translation or further explanation was available upon request. Clinical staff also provided information during individual visits or telephone calls.
Data and definitions
All queries were performed using the Resource and Patient Management System (RPMS) database (Office of Information Technology, IHS, Albuquerque, New Mexico). RPMS is an IHS software package used to compile the patient registry and electronically record information from medical records following every patient encounter. Data are recorded into the database directly from EHR entries and through data entry following visits recorded on paper charts from clinics or services not yet using the EHR.
We evaluated GPRA reports to compare recent and historic local and national PPV coverage, and performed a separate database analysis for high-risk groups in 2007. GPRA analyses had been performed previously for quality improvement purposes, used throughout the IHS to assess progress in multiple areas of health-care provision including pneumococcal vaccination coverage, as mandated by federal law for facilities receiving federal funds. Annual GPRA reports include data collected through fiscal years ending on September 30. GPRA analyses are standardized throughout the IHS and use database queries for all indicators. National GPRA PPV analyses are only available for the risk group of adults ≥65 years of age using the GPRA active clinical population, and locally for people ≥65 years of age and people with diabetes using active clinical, active diabetic, and user population definitions. Pneumococcal vaccination indicator analysis uses three population definitions. For WRSU, these are:
- The GPRA user population, defined as AIANs alive throughout the evaluation period residing in a community within the WRSU “catchment area” (which includes the 2,500-square-mile reservation and non-reservation communities up to 75 miles from the hospital) who had a WRSU visit during the three years prior to the end of the report period;
- The GPRA active clinical population, defined as people who met the criteria for the GPRA user population and had two visits to medical clinics in the three years prior to the end of the report period; and
- The GPRA active diabetic population, defined as people among the active clinical population who had diabetes diagnosis confirmed at least one year prior to the report period, and had at least two WRSU visits in the past year and two diabetes-related visits ever.
These population definitions are established at a national level and were used in this study to allow consistent comparisons. Within our user population, 14,549 people of all ages are listed as living on the Fort Apache reservation, compared with the 2000 U.S. Census figure of 12,429. The user population definition excludes AIANs in the service unit registry who list an address within the service unit catchment area but have not visited the service unit in three years, so that those who have moved away, died, or received services elsewhere without database recognition are not included in GPRA measures. There are 3,388 people in the registry of this designation who do not meet the user population definition. A total of 1,089 (32%) are 20–29 years of age, and six are more than 100 years of age (likely deceased but unrecognized as such in the registry).
We performed 2007 database query analysis of risk groups ending December 31, 2007, using the GPRA user population, as the user population is a standard population definition used throughout the IHS that facilitates comparison with other IHS facilities and captures a large proportion of the community population. Medical conditions were identified through database queries using International Classification of Diseases, Ninth Revision (ICD-9) codes for high-risk conditions diagnosed at least one year prior to the last day of the study period (December 31, 2007). We performed a separate query for people receiving immunosuppressive therapy, as this information could not be captured through an ICD-9 code query.
We considered an individual to have an indication for PPV if he or she was ≥18 years of age with an underlying condition as defined by ACIP14
addressed at least once in the previous five years, or ≥65 years of age. We defined alcoholism as a clinical diagnosis of alcoholism, a history of complications related to alcohol use, or one or more medical visits associated with alcohol use in the previous five years. We defined generalized malignancy as a malignant neoplasm spread beyond an in-situ lesion or a neoplasm treated with systemic chemotherapy or radiation. We reviewed purpose-of-visit narratives to verify staging status of neoplasms, and used manual and/or electronic reviews to verify diagnoses and conditions. We reviewed purpose-of-visit narratives and records of people with diagnoses listed fewer than three times during 2003–2007 to verify diagnosis.
Because GPRA analyses for PPV coverage do not evaluate high-risk condition groups other than those ≥65 years of age or people with diabetes, we performed database queries for 2007 PPV coverage rates for all high-risk conditions among those aged 18–64 and ≥65 years. In this analysis, we used the GPRA user population because the user population may reflect the actual residential population more closely than the active clinical population. We performed database queries and electronic and manual chart reviews to determine number of refusals and to adjust for inaccurate or incomplete query information.
We used GPRA analysis reports, using GPRA active clinical population definitions and database queries, to compare WRSU 2007 PPV coverage rates with rates in previous years and to aggregate rates of the IHS, as GPRA reports are standardized and reported annually. National GPRA analyses of health indicators are performed using data from up to 191 health-care facilities and more than 1.2 million patients throughout the Indian health delivery network, although not all facilities participate in each health indicator analysis.
GPRA reports used the GPRA active diabetic population (locally) and the GPRA active clinical population ≥65 years of age (locally and nationally). Those with a documented PPV receipt any time prior to the end of the report period are identified as vaccinated against pneumococcus, and because GPRA tracks people who are offered vaccine, refusals are categorized as vaccinated. All others are considered unvaccinated. The 2007 non-GPRA database analysis counted refusals as unvaccinated.