In a recently released article in Pediatrics, Dr. Adam Yan and colleagues share a quality improvement (QI) project which successfully increased rates of receipt of >2 COVID-19 vaccinations among children ages 5 years and older with sickle cell disease (SCD) cared for in their SCD clinic (10.1542/peds.2022-061011). As context, the authors note that although most children with COVID-19 have mild and self-limited respiratory illness, those with chronic illnesses including SCD are at risk for severe disease. Specifically, COVID-19 can trigger pain crises and acute chest syndrome and put children and adults with SCD at risk for hospitalization and death, and hence the Centers for Disease Control and Prevention (CDC) prioritized those with SCD to receive COVID-19 vaccination. Although nationwide data for vaccine uptake among children with SCD are not available, the authors hypothesized that children with SCD and their families may face meaningful barriers to vaccination, including distrust associated with racial mistreatment and logistical barriers.
Their initiative is a classic and beautiful example of QI work, and readers are walked through each step in the process. The primary interventions, based on literature review, were personalized text messages and reminders, outreach with phone calls and an informational video created by the project team and distributed by text message. The authors’ key driver diagram (Figure 1) gives readers a snapshot overview of the project, including their Specific, Measurable, Achievable, Relevant, and Time-Bound (SMART) aim of vaccinating 70% of patients by June 2022. In an additional analysis, the authors used statistical modelling techniques to compare the predicted and achieved rates of vaccination in order to account for pre-existing vaccination trends.
Each PDSA (Plan, Do, Study, Act) cycle is clearly explained, with additional interventions focused not just on families and patients but also on provider coaching:
- Identification of the COVID-19 vaccination status of those with SCD aged 5 years and older with targeted text messaging.
- Re-identification of those not vaccinated with targeted phone calls to schedule a vaccine appointment.
- Texting of the educational video to those not vaccinated with information on how to schedule a vaccine appointment.
The article addresses all the “messy” parts of clinical medicine that had to be tackled for the initiative to proceed, from patients who obtained vaccines elsewhere, to families with vaccine hesitancy and scheduling challenges. Ultimately, during the intervention period, the cumulative proportion of patients who received >2 COVID-19 vaccine doses increased from 41% to 64%, closely approaching the SMART aim of the project and exceeding the predicted rate by 11%. Although the authors do not explicitly state so, this QI initiative is important also for its role in supporting racial equity with respect to a key health intervention, since the great majority of those with SCD are of African-American ancestry with documented inequitable care and care access contributing to poorer health outcomes in comparison to those without SCD and the general population.1,2 Kudos to the authors for this successful initiative, which hopefully serves as an inspiration for others!
- Lee L, Smith-Whitley K, Banks S, Puckrein G. Reducing Health Care Disparities in Sickle Cell Disease: A Review. Public Health Rep. 2019 Nov/Dec;134(6):599-607. doi: 10.1177/0033354919881438. Epub 2019 Oct 10. PMID: 31600481; PMCID: PMC6832089
- Boghossian NS, Greenberg LT, Saade GR, Rogowski J, Phibbs CS, Passarella M, Buzas JS, Lorch SA. Association of Sickle Cell Disease With Racial Disparities and Severe Maternal Morbidities in Black Individuals. JAMA Pediatr. 2023 Aug 1;177(8):808-817. doi: 10.1001/jamapediatrics.2023.1580. PMID: 37273202; PMCID: PMC10242511