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Abstract
Introduction In 2022, the Advisory Committee on Immunization Practices (ACIP) updated its recommendation regarding hepatitis B vaccination and advised vaccination for all adults aged 19–59 regardless of risk factors and those 60 years and older with risk factors. Adults 60 years and older without known risk factors may also be vaccinated. Our project aimed to spread awareness of the updated hepatitis B virus (HBV) vaccination guideline and improve HBV vaccination rates among veterans in a resident-based primary care clinic.
Methods Preintervention data were collected from October to December 2021 and post intervention data were collected from March to May 2022; patients seen in the clinic during these months were included. Patients were considered immune against HBV if they had positive anti-hepatitis B surface antigen and susceptible to infection if the hepatitis B panel was negative. Interventions included educating each resident group regarding current guidelines via multifaceted modalities. In addition, a reminder for checking hepatitis B status was embedded in the veterans affairs (VA) electronic medical record.
Results In the preintervention period from October to December 2021, a total of 1242 veterans were seen. 532 veterans had previous screening for hepatitis B immunity in the chart with 378 veterans negative for hepatitis B surface antibody. Of those 378 veterans, only 35 were vaccinated against hepatitis B during the time period studied. In the postintervention period, 1174 veterans were seen and 559 had prior hepatitis B immunity screening with 430 veterans negative for hepatitis B surface antibody. Of the 430 veterans with no immunity against HBV, 123 received hepatitis B vaccination during the time period studied, which is an increase of greater than 20% in the number of veterans vaccinated.
Discussion Our data suggest that HBV vaccination rate was suboptimal among the veteran population. A low-cost intervention could be beneficial in integrating new vaccination guidelines in the VA standard of care. Increased awareness of the updated HBV vaccination guideline would likely help to achieve the goal of full vaccination among the veteran population.
- Quality improvement
- GENERAL PRACTICE
- Clinical practice guidelines
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
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WHAT IS ALREADY KNOWN ON THIS TOPIC
Hepatitis B virus (HBV) vaccination had long shown efficacy and safety; however, vaccination rate among the adult population is still suboptimal. In 2022, Advisory Committee on Immunization Practices (ACIP) updated its risk factor-based hepatitis B vaccination guideline and recommended vaccinating all adults aged 19–59 and those 60 years and older with risk factors.
WHAT THIS STUDY ADDS
We started this quality improvement project as we noticed that the HBV vaccination rate among veterans was low. Our study showed that simple interventions with the help of technology can increase awareness among physicians and improve HBV vaccination rate among the veteran population.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
This study demonstrates that stepwise reinforcement is necessary for new clinical guidelines to become standard of practice. As a result, it is necessary to invest time in spreading awareness after new guidelines are publicised, for them to be properly integrated into practice.
Background
Hepatitis B is a vaccine-preventable liver infection caused by the hepatitis B virus (HBV). In the Veterans Affairs Medical Center (VAMC) located in Long Island, New York, we noticed that vaccination rates for HBV among veterans in a resident-based primary care clinic were low. Our project studied the implementation of a low-cost electronic reminder for vaccination status check during each patient visit along with multimodal educational interventions, and its efficacy in improving HBV vaccination rates among veterans.
It is known that hepatitis B is spread via blood, semen, or other body fluids, which can occur through sexual contact, needle sharing or mother-to-baby at birth. Most people can clear the virus without issue. For some, hepatitis B may become a chronic infection that can lead to subsequent serious complications, such as cirrhosis or hepatocellular carcinoma. The best way to prevent hepatitis B infection is through vaccination, which is safe and effective.1 In the past, vaccination was recommended to adult patients based on risk factors. Persons are at risk for HBV infection if they are sex partners of persons who tested positive for hepatitis B surface antigen, are men who have sex with men, have a history of current or recent injection use, are positive for hepatitis C virus or HIV infection.
In 2019, the Advisory Committee on Immunization Practices (ACIP) noted that half of the acute hepatitis B cases were diagnosed in patients ages 30–49, and cases among adults aged 40 years and older were rising.2 Although HBV vaccine was proven to be safe and effective, less than a third of US adults reported being vaccinated against hepatitis B in 2018.3 Seeing that the strategy to offer HBV vaccine based on individual risk assessment could be suboptimal, the ACIP updated its vaccination recommendation in 2022. ACIP now recommends HBV vaccination for all adults ages 19–59 years and those age 60 years and older with risk factors for HBV infection. Those who are 60 years and older without risk factors may also be vaccinated.1 In conclusion, all adults aged 19 and above should be offered the hepatitis B vaccine if they have not been vaccinated, regardless of associated risk factors.
Assessment of problems
Given that the hepatitis B vaccination recommendation was recently changed in 2022 during the ongoing COVID-19 pandemic, clinicians may have overlooked the new recommendation. In addition, new guidelines require time for education and implementation before becoming the standard of care. As such, our interventions focused on spreading awareness of the new changes to providers working in primary care and using an electronic reminder to check hepatitis B immunisation status during patient visits. These interventions helped to solidify the updated recommendations into the standard of practice within the veterans affairs (VA) system with the hope to lower cases of acute hepatitis B infection.
It was noted that hepatitis B vaccination rates were suboptimal among the veteran population in Long Island, New York. Thus, our project aimed to encourage clinicians to routinely offer hepatitis B vaccination for eligible patients and thereby improve the vaccination rate among veterans.
The VAMC in Long Island is a teaching institution where residents from different specialties rotate periodically. This project occurred specifically in the VA resident-based primary care clinic where one group of internal medicine residents rotated through every fifth week, for a duration of 1 week. During a clinic week, residents were responsible for seeing patients and ordering appropriate lab testing, vaccinations and medications. At the end of each patient visit, residents completed a reminder list that was incorporated into each patient’s electronic chart. The reminder list only contains items that have not been addressed previously, such as influenza vaccination during the influenza season, depression screening, colonoscopy screening, and so on. Items that were previously addressed will not show up on the reminder list to avoid informational fatigue.
Strategies for quality improvement
A review of research that studied barriers to the implementation of evidence-based clinical guidelines into practice showed that there were multiple barriers affecting physicians from integrating guidelines into practice. The best strategies were the ones that addressed barriers related to specific practitioners, social and organisational contexts.4 To maintain behavioural changes, multifaceted interventions involving multiple strategies were more effective than a single intervention.5 Keeping this in mind, we came up with different low-cost and sustainable interventions targeting multiple facets of the root problem of low hepatitis B vaccination rates in the veteran population.
Several studies cited awareness as one of the most common barriers to updated guideline adherence.6 Given how recently the new hepatitis B recommendation was updated by the ACIP, we suspected that most residents in the VA primary care clinic were not yet aware of the change. In addition, as mentioned by Sadeghi-Bazargani, Homayoun et al7 lack of time to search, study and learn from studies was a barrier reported by physicians. Therefore, as our initial step, we sent out an email containing the updated hepatitis B vaccination recommendations to all 50 residents and 7 attendings working in the VA prior to the start of their clinic week and stressed that the vaccination recommendation was no longer based on risk factors. In the email, we stated that all adults aged 19 or above should be offered HBV vaccination if appropriate and emphasised that physicians should initiate the discussion on HBV vaccination instead of waiting for a patient to request it. For our second step, we hosted oral presentations to go over the details stated in the email. We also answered questions from all resident groups and reviewed logistics such as how to order the vaccine and how to document prior vaccination.
In the study by Cabana et al,6 familiarity was cited as another common barrier to guideline implementation. Even if a clinician was aware of the new changes, not being familiar with the details may still prevent one from putting new recommendations into practice. Thus, we created a poster outlining the new recommendation details and placed it in all the resident clinic rooms for ease of reference during patient visits. An example of the poster was shown in figure 1. All the above interventions were carried out in the month of January–March of 2022. We aimed to reinforce awareness among the residents as the initial step in changing the standard of care.
Hepatitis B vaccination poster. Example of a poster placed in each exam room, an intervention used to remind all primary care physicians to check each veteran’s hepatitis B vaccination status at the end of the visit.
Example of electronic reminder for checking hepatitis B vaccination status that was developed and embedded into veterans affairs (VA) electronic medical record system. This reminder will show up at the end of each visit if veteran has no records of hepatitis B immunisation record on file.
As the residents became more familiar with the new changes, an electronic reminder was also integrated into the VA electronic medical record (EMR) at the end of March 2022. The electronic reminder asked if a veteran was vaccinated against hepatitis B, which would prompt the physician to check a veteran’s vaccination records and offer the HBV vaccine, if appropriate. An example of the HBV electronic reminder was shown in figure 2.
It should be noted that the VA EMR only records vaccinations if they are obtained in a VA setting or if proof of vaccination is provided. Per CDC, persons who have completed an HBV vaccination series at any point or who have a history of HBV infection should not receive additional HBV vaccination, although there is no evidence that receiving additional vaccine doses is harmful.1 Although prevaccination testing with a hepatitis B panel is not mandatory, most of our veterans could not remember if they received the HBV vaccine before or if they had prior hepatitis B infection. The CDC alternative in populations with high rates of prior HBV infection is to perform prevaccination testing concomitantly with administration of the first dose of vaccine and decide on administering the second dose base on testing results.1 For cost-effective purposes, we opted to check hepatitis B panels on veterans who had neither screening nor vaccination records on file. Veterans without hepatitis B immunity were then offered HBV vaccination.
We assessed the impact of our intervention by collecting data prior to and after our interventions. All patients seen in the resident-based primary care clinic in the months of October–December 2021 were included in the preintervention group. All patients seen in the months of March–May 2022 were included in the postintervention group. We measured HBV vaccination rate in veterans that were not previously vaccinated before and after our interventions to assess the impact of our interventions.
Results
Table 1 demonstrates basic demographic information of the veterans that were seen in the clinic prior to and after our interventions. Data were collected in the preintervention period between October and December 2021; 1242 veterans were seen in the resident-based primary care clinic. Five hundred thirty-two veterans had a prior hepatitis B panel recorded in the EMR for which no immunity to HBV was observed in 378 of them. Out of the 1242 veterans seen in the clinic, 84 veterans were previously vaccinated for hepatitis B and 35 veterans were vaccinated during the preintervention period between October and December 2021.
Basic demographic of veterans seen in primary care clinic
In the postintervention period, 1174 veterans were seen in clinic; 559 veterans had a prior hepatitis B panel recorded in the EMR for which no immunity to HBV was observed in 430 of them. Out of the 1174 veterans seen in clinic, 128 veterans were previously vaccinated for hepatitis B and 123 veterans were vaccinated during the postintervention period between March to May of 2022. For comparison, postintervention data showed that 123 veterans without immunity to HBV received the HBV vaccine during their primary care visit versus 35 veterans in our preintervention data.
It should be mentioned that after each resident finished seeing his or her patient, he or she needed to discuss each case with the supervising physician regarding a finalised assessment and plan. As a result, if a resident forgot to check a veteran’s hepatitis B vaccination status, it was the attending physician’s responsibility to remind the resident regarding hepatitis B guidelines. It was therefore equally important to update the attending physicians working in the resident clinic on the new guidelines to facilitate the incorporation of hepatitis B vaccination into daily practice. Although a survey for feedback was not performed after our interventions, we received feedback from attendings stating that most residents were not aware of the change in HBV vaccination guidelines prior to our interventions, however eventually became familiar with the updated guidelines after our multimodal interventions.
Unanticipated issues were also observed during the implementation of our project. When hepatitis B vaccination was offered to veterans lacking immunity, some veterans declined vaccination. Some common reasons for declination included the inconvenience of the three-dose vaccine when veterans must return to complete the series, difficulty finding transportation to the VA, or beliefs that they would not contract hepatitis B. Further intervention may be necessary to address vaccine hesitancy and promote the benefits of hepatitis B vaccination to veterans during a clinic visit.
Discussion
All interventions were designed specifically with the goal of improving the hepatitis B vaccination rate among veterans seen in our VA primary care clinic. As the interventions were created to address likely barriers providers faced to have veterans obtain the hepatitis B vaccine, we believe the observed outcomes were directly associated with our multifaceted interventions.
With the ultimate goal of eliminating hepatitis B worldwide, there were multiple studies examining the barriers to achieving that goal. Not surprisingly, different barriers were identified based on location and target population, and interventions were developed accordingly. For one study done in China,8 fee for vaccination was a significant barrier for adult patients receiving vaccines; a hypothetical policy that offered vaccination free of charge would likely surge hepatitis B vaccination rates based on a questionnaire passed out to 22 618 adults. In another study done in Singapore,9 poor knowledge regarding HBV was a significant predictor for citizens not to undergo HBV screening while lack of prior HBV screening became the most significant barrier to receiving the vaccine. Another study was done in Canada focusing on the immigrant population,10 which showed that limited knowledge about HBV vaccination and English proficiency were among the most identified barriers to care.
Back in the USA, most studies were done prior to the updated HBV vaccination guidelines. In a study published in 2014,11 a survey regarding hepatitis B vaccination and screening awareness was passed out to 400 physicians from all over Wisconsin. Based on the survey answers, it seemed that primary care physicians were unable to consistently identify relevant risk factors and offer HBV screening as appropriate. Even if risk factors were known, routine screening may not have occurred due to various barriers, such as the time needed for discussion during each visit and the cost of screening, according to statistics from the survey.
Different quality improvement interventions had also been initiated to improve HBV vaccination rates. In a quality improvement initiative targeting patients with chronic kidney disease,12 awareness and time constraints during appointments were identified as the major barriers for which several interventions were implemented to meet a monthly vaccination goal of 75% of eligible patients. In order to spread awareness of HBV vaccination, they arranged presentations at multiple divisional rounds, placed clinic-wide memos along with workroom posters, and sent out individual physician emails as an additional reminder. For patients eligible to receive the HBV vaccine, scheduling staff scheduled additional time for the appointment to allow enough time for a discussion between the patient and physician, and the first dose of the HBV vaccine if the patient agreed. Nursing and scheduling staff arranged subsequent follow-up appointments together for the next dose of the HBV vaccine. With these interventions, the study saw a 46% increase in vaccination compared with preintervention as the vaccination rate eventually reached above 75%.
We developed this quality improvement project in alignment with the goal set by the WHO. The Global Health Sector Strategy on Viral Hepatitis, 2016–202013 adopted by WHO proposed strategies for the elimination of viral hepatitis by 2030, defined as a 90% reduction in new chronic infections and 65% reduction in mortality, compared with the 2015 baseline. To support countries in achieving global targets, WHO worked to raise awareness, formulate evidence-based policy for action, and implement screening and treatment services. As an example, the WHO organised annual World Hepatitis Day campaigns to promote the understanding of viral hepatitis to the general public. To contribute to the global target within the VA population, we formulated interventions that align with the WHO recommendations with the hope to have an impactful change.
One opportunity cost observed was further time constraints for nursing staff and residents alike. For nursing staff, they needed to allocate more time for administering HBV vaccines as more veterans were now eligible for it. As a result, the nursing staff had less time to complete routine triage questionnaires, such as depression screening or housing screening.
Residents needed more time to complete the HBV reminder list, which included checking HBV screening and vaccination status, and offering HBV vaccination if appropriate. Given that the length of each appointment was standardised, residents had to learn to prioritise tasks accordingly.
Limitations
There were several limitations to our study. Our study was conducted in the setting of a VAMC where everything was centralised. All veteran records were conveniently found on the VA-specific EMR, which made the search for HBV screening and/or vaccination status simpler. In addition, an on-site laboratory posed a convenience for veterans to get screened with a hepatitis B panel. We also had motivated scheduling staff, nursing staff and residents who contributed significantly to all parts of our project. All the aforementioned items may not be readily available in other healthcare settings and thus less generalisable in more resource-constrained settings.
In addition, our study did not seek repeat titers after vaccination to ensure an appropriate response to HBV vaccination. While we did not have a standardised plan for veterans with negative titers after full vaccination, we saw that this could be an area of improvement as our project progressed.
Given that multiple interventions occurred at the same time, it was difficult to predict which intervention was the most effective. The sustainability of each intervention was also not the same as we sent emails and held oral presentations for about 2 months while the hepatitis B reminder in the EMR was permanent.
Conclusions
We believe the incorporation of the EMR reminder will make this project sustainable as residents would routinely be reminded to check HBV status, and thus create a habit that will be integrated into each patient visit. The potential to use similar interventions to improve the vaccination rates of other vaccines is also a possibility. We hope that the initiation of our project would not only serve to align with goals set by the WHO for the elimination of new chronic hepatitis B cases but that residents would also learn to routinely incorporate new evidence-based guidelines into their professional careers. This project would be useful to orient trainees to the process of gaining awareness, intervening and incorporating other medical recommendations into practice in the future.
Other information
The above manuscript is written according to the Standards for Quality Improvement Reporting Excellence (SQUIRE) 2.0 guideline.14 The SQUIRE guidelines are intended for reports that describe system-level work to improve the quality, safety, and value of healthcare, and used methods to establish that observed outcomes were due to the intervention(s).
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
Not applicable.
Footnotes
Contributors Both authors designed and directed the project. Both authors wrote the manuscript. ZLY will be the guarantor of this manuscirpt.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.