Pneumococcal Vaccination in Adult Patients with Chronic Obstructive Pulmonary Disease

Pneumococcal Vaccination in Adult Patients with Chronic Obstructive Pulmonary Disease
The pneumococcal vaccination is recommended for all adults age 65 or older, particularly for people with lung diseases like Chronic Obstructive Pulmonary Disease (COPD) (CDC, 2022). Pneumococcal immunization prevents invasive infections like COPD and reduces the severity in vaccinated adults (CDC, 2022). COPD is a chronic illness that is marked by a dysfunction of the airways or alveolar following exposure to hazardous fumes or particulates leading to continual airflow obstruction or respiratory symptoms (Ignatova et al., 2021). Periodic exacerbations can lower the quality of life in COPD patients due to pneumonia and could lead to unwanted outcomes, including mortality, and morbidity (CDC, 2022; Ignatova et al., 2021). An evidence-based approach used to minimize the likelihood of COPD exacerbation is the use of influenza vaccination and pneumococcal vaccine to prevent the development of pneumonia in adult COPD patients (Ignatova et al., 2021). Despite the existence of evidence indicating that vaccination is an effective preventive measure that can minimize the exacerbations of COPD and lower the likelihood of contracting pneumonia, the uptake of the vaccine remains suboptimal.
Walters et al. (2017) have shown that a pneumococcal vaccine is an effective approach for reducing the likelihood of pneumonia infections in adult COPD patients but their uptake remains minimal. A study by Fekete et al. (2020) showed that the uptake of pneumococcal vaccine among adult COPD patients was 10 percent despite the evidence of the significant protective effect of the vaccine in adult COPD patients. Based on the Centers for Disease Control’s (2022) data on the prevalence of COPD, the prevalence of the disease has remained unchanged between 2011 and 2020. The overall age-adjusted prevalence of the disease was 5.6, with the prevalence being significantly higher in women than in men and Streptococcus pneumoniae-associated infections cause significant morbidity and mortality in older adults.
Notably, the death rate due to COPD has reduced from 123.9 per 100,000 reported in 1999 to 105.6 per 100,000 reported in 2019, with mortality in men being higher compared to women population (CDC, 2022). The figures are in line with studies that have placed chronic lower respiratory disease including COPD as the fourth leading cause of mortality in the United States in 2019 (Wise, 2022). The death rate associated with COPD has only slightly declined despite the introduction of a vaccine as a potential preventive measure that can assist in reducing the occurrence of COPD exacerbation and minimizing pneumonia infections (Ignatova et al., 2021). In addition, the economic burden of COPD is staggering, with studies showing that the disease will lead to incurred costs of US$ 49 billion in 2019, mainly driven by hospitalizations (Wise, 2022). Thus, immunization in older adults is a vital component of preventive healthcare administrations to avert infectious illnesses like flu and pneumococcal illness (e.g., pneumonia, otitis, sinusitis), reduces illness and mortality, and decreases complications and hospitalizations (Bach et al., 2019).
The purpose of the project is to increase the pneumococcal vaccination rates among adult COPD patients. After a literature review and a needs assessment, a PICOT question to guide the project was formulated as follows: Among adult COPD patients, what is the impact of phone call reminders compared to no phone call reminder on the total number of recorded vaccinations from January 2023 to March 2023? Therefore, the purpose of the project will be the implementation of phone call reminders to increase the rates of pneumococcal vaccinations among adult COPD patients. To this end, the overall objective is to increase the vaccination rate by 10% from January 2023 to March 2023 in adult COPD patients. The primary outcome measure will be a percentage increase in the pneumococcal vaccinations recorded in adult COPD patients, while the secondary measure will be to determine the effectiveness of the telephone reminder in increasing the pneumococcal vaccination rate.
Review of the Literature
To determine the viability of the proposed evidence-based project, it was essential to search relevant literature indicating that the adoption of the phone call reminder would be effective in increasing the adoption of pneumococcal vaccination among adult COPD patients. The databases that were used are CINAHL, PsycINFO, Medline, Web of Science, IMMER, Embase, and Cochrane. Also, other open-access databases and websites were accessed through the Library of the University of Missouri St Louis (UMSL), the Center for Disease Control (CDC), The Cochrane Library, National Institute for Health and Care Excellence (NICE), Campbell Library of Systematic Reviews, ICA Health Communication (a Johns Hopkins University database), OpenGrey, Copac National, Academic, and Specialist Library Catalogue, GAVI Alliance (Global Alliance for Vaccination and Immunization). The main keywords that were used to complete the search and the identified databases were “pneumococcal vaccination,” “vaccination”, “COPD”, “phone call reminder,” “benefits,” and “adult COPD patients”. To ensure that the study findings were current, the sources were limited to those published from January 2017 to November 2022. Only studies published in English that had the specified keywords in their title and abstract sections were included in the study. Notably, the search included all forms of peer-reviewed studies not limited to clinical trials, meta-analyses, descriptive studies, and systematic reviews, among others. No editorials, conference abstracts, or commentaries were included. Likewise, articles with irrelevant topics, without abstracts, and minus a clear target population were excluded.
Following the compilation of the results from all the major databases, 57 sources relevant to the current study were identified. Of these, 11 studies were relevant to the current study and are included in the project proposal. Based on the guideline provided by the Agency for Healthcare Research and Quality (AHRQ), the identified pieces of literature were two meta-analyses and two systematic reviews (Level I), four randomized control trials (Level II), and three qualitative and quantitative studies (Level IV).
Level I Evidence
Cafiero-Fonseca et al. (2017) identified 5,857 papers published between January 2010 and April 2016 on pneumococcal vaccination in adults. The studies reported that the uptake of pneumococcal vaccination resulted in health gains for the patient as well as contributed to significant savings in healthcare costs. Notably, some of the studies went further and captured the additional benefits of pneumococcal vaccination such as the increased levels of productivity. Notably, the review may be limited due to several limitations of some studies included in the review such as the inclusion of only abstracts in some of the studies.
Walters et al. (2017) conducted a systematic review to determine the effectiveness of pneumococcal vaccines in the prevention of pneumonia in adult COPD patients. The researchers searched for all the studies published on the effectiveness of the pneumococcal vaccine up to November 2016. The researchers retrieved 12 studies with 2,171 participants. Walters et al. (2017) found that the vaccinated adult COPD patients had minimized the likelihood of developing pneumonia in the community. In addition, the vaccine reduced the likelihood of exacerbation of COPD in patients at statistically significant levels. Nonetheless, the findings did not find significant differences in the effect of vaccination on hospital admissions or reduction in mortality among the controls and the intervention groups.
Kuehne et al. (2020) examined the effectiveness of involving patients in the decision-making process on pneumococcal vaccine uptake. From eight studies, the researchers found that the exchange of information with patients using interventions such as phone call reminders enhanced pneumococcal vaccine uptake compared to the control group. Nonetheless, the quality of evidence was low. 
Tretheway et al. (2019) conducted a scoping review to determine the effectiveness of phone call reminders in enhancing pneumococcal vaccination rates among adults. Following a literature search, the researcher picked seven articles reporting on potential interventions that could be used to enhance pneumococcal vaccination uptake. The findings suggest that patient-focused approaches such as the use of phone call reminders can improve the uptake of pneumococcal vaccination among adults. Nonetheless, the researcher cited a lack of high-quality studies. Jacobson Vann et al. (2018) conducted a systematic review to examine the effectiveness of various interventions intended to increase vaccination uptake including phone call reminders. The researchers found that the use of phone call reminders could improve the uptake of vaccinations among adults using moderate certainty evidence from 15 studies.
Level II Evidence 
Ho et al. (2019) conducted a cluster randomized controlled trial measuring the effectiveness of point-of-care informational interventions on the uptake of pneumococcal vaccination. The study was conducted in 22 private clinics in Singapore and covered all patients above 65 years. 4378 patients were included in the study. The rate of pneumococcal vaccine uptake among the participants was 5.7 percent during the intervention period, which was higher than the 3.7 percent rate reported during the control period.
Stolpe and Choudhry (2019) conducted a study to examine the effectiveness of automated telephone reminders on the uptake of pneumococcal vaccines among adults visiting a community pharmacy. The researchers identified 21,791 patients with vaccine gaps using the data from the pharmacies and randomly assigned them to either a group that received telephone reminders for pneumococcal vaccines based on the patient records or a group that received usual care. The two groups were tracked between March 2016 and January 2017. The researchers did not observe marked differences in vaccine uptake between the two groups. However, it is important to note that the effectiveness of the application of phone call reminders in the study could have been compromised by technical challenges in the implementation, the minimal connection with the patients, the absence of follow-up, and patients’ ignorance of the importance of pneumococcal vaccinations. 
In a similar study, Klassing et al. (2017) conducted a randomized control trial to examine the effectiveness of a pharmacist-initiated intervention on the vaccine uptake among adult COPD patients. 210 patients from three community pharmacies were randomized to a control group, a group that received letter reminders, or a group that received phone call reminders. Notably, the results showed that a higher number of participants had vaccine uptake following a phone call reminder than the control group or those who received mailed letters.
Level IV Evidence
Fathima et al. (2021) conducted a pilot study to examine the effectiveness of the pharmacy care model for adult COPD patients that included the use of phone call reminders over a period of six months. Forty pharmacies were recruited for the pilot study, with nine of them recruiting 27 adult COPD patients into the program. The program reported 119 referrals to general practitioners for pneumococcal vaccination among other services. Nonetheless, the generalizability of the study findings to the general population remains unclear.
Level V Evidence
In a review of intervention, Bach et al. (2019) provide an expert opinion on the common barrier to vaccination uptake among adult COPD patients. Following their examination of the literature, Bach et al. (2019) noted that phone call reminders were one of the potential interventions that were shown to be highly effective in increasing immunization rates in populations. Andreoni et al. (2021) recommended the clinical use of phone call reminders as one of the potential interventions that could be effectively used to improve the levels of vaccination uptake among the adult population including COPD patients. The recommendation is based on the advice from the major Global Institution Organizations and also reviews the comorbidities that are associated with diseases such as COPD and the potential benefits of vaccinations.
Froes et al. (2017) provide an expert opinion on the benefits of pneumococcal vaccines for adult COPD patients. The review of studies on vaccine efficacy shows that the combination of influenza and pneumococcal vaccine can be effectively used to reduce infection and the exacerbation of COPD. Notably, the vaccines are especially effective in older adults, especially if the pneumococcal vaccine is taken during the early cause of COPD diagnosis.
Synthesis of the Literature
Notably, there is sufficient evidence from the literature review to indicate that the uptake of the pneumococcal vaccine among adult COPD patients has benefits (Rochi & Blasi, 2017; Walters et al., 2017; Cafiero-Fonseca et al., 2017)). To this end, Rochi and Blasi (2017) report that combining the pneumococcal vaccine with the influenza vaccine decreases the exacerbation of COPD and lowers the likelihood of pneumonia infections in adult COPD patients. Cafiero-Fonseca et al. (2017) report that the use of pneumococcal vaccination lower healthcare cost and improves the health status of adult COPD patients, with Walters et al. (2017) reporting that the use of pneumococcal vaccine minimizes the likelihood of a patient experiencing community-acquired pneumonia and the exacerbations of COPD in patients. Evidently, there is sufficient evidence to support the effectiveness of the pneumococcal vaccine in adult COPD patients.
Further, there is sufficient evidence that the use of phone call reminders was an effective intervention for increasing pneumococcal vaccinations among adult COPD patients (Kuehne et al., 2019; Ho et al., 2019). All the studies noted that healthcare organizations that used phone call reminders reported increased uptake of pneumococcal vaccines among adult COPD patients. However, Stolpe & Choudhry (2019) found that the use of phone reminders did not result in significant differences in the uptake of the pneumococcal vaccine among patients recruited from the pharmacy. Notably, the differing result could be explained by the limitations of the study. Studies by Fathima et al (2021) and Klassing et al. (2017) reported positive results in a pharmacy setting.
Theoretical Framework
The research project will be guided by the Iowa Model of Evidence-based Practice to Promote Quality Care which was developed with threefold goals of enhancing patient care, facilitating nursing practice, and lowering healthcare costs. To this end, the model encourages the implementation of evidence-based projects that are triggered by a clinical problem or the availability of new knowledge. In line with this, the low number of adult COPD patients who have received the pneumococcal vaccine despite its proven efficacy informs the current Doctor of Nursing Practice Project. 
Notably, the IOWA model will provide a systematic process that will guide the implementation of the project. The model will be appropriate for monitoring and analyzing the structure, process, and outcome data in terms of environment, staff, cost, and patients. Once the trigger will be evident, the next step will be determining the extent to which the problem was a priority for the site before proceeding to collect the research that would inform the proposed practice change. The IOWA model will help to identify the study question, determine the problem, form a team, perform a literature review, implement the change, and also evaluate the results for this project. The change will be implemented and the results will be evaluated to determine the feasibility of the evidence-based practice with the help of the IOWA model. 
Method Plan
Design:
The project is a quality improvement project using evidence-based interventions to increase the vaccination rate in the adult population. Through the retrospective, descriptive, comparative method, the project will evaluate the vaccination rate with the implementation of phone-call reminders in adult COPD patients.
Setting:
This project will take place in Healthy Living Primary Care. Healthy Living Primary Care is located in Kentucky whose mission is to implement a wellness-based model and provide evidence-based, individualized care to patients. There are 3 primary care providers, 1 Registered Nurse (RN), and 3 Medical Assistants (MA) working in this facility. The healthcare providers include a physician working a 10-hour week and other two nurse practitioners working full-time. Healthy Living Primary Care approximately has 300 patients as well as some walk-ins daily. The patients are of all ages including adults more than 70%. The setting has different facilities including vaccination facilities for children and adults. The MAs use phone call reminders to remind patients of their appointment the day before the appointment.
Sample:
This project will use a convenience sample of adult COPD patients who are 65 years and older who are eligible for pneumococcal vaccination and who have access to a telephone. Adult COPD patients less than 65 years of age who are not eligible for pneumococcal vaccination and who don’t have access to a telephone will be excluded. A unique alphanumeric identifier will be created and applied to each primary care provider for identification purposes. The identifier will be a combination of the patient's first and last initials and date of birth (eight digits -month/day/year), generating a unique ten-digit identifier. A master list of coded identifiers and patient names will be stored in a password-protected file on the primary investigator’s clinic-provided laptop.
Approvals:
Formal, written approval will be sought and obtained from Healthy Living Primary Care. The project protocol was evaluated and determined not to be human-subject research. The approval for this project will be sought from the University of Missouri- St. Louis (UMSL) Institutional Review Board (IRB) before implementation. Healthy Living Primary Care does not have Institutional Review Board (IRB) and will provide a letter saying that this project can be carried out in the organization.
Data Collection/Analysis:
The data collection tool will collect patients' information, such as age, gender, sex, ethnicity, and patient getting vaccination with...