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Collective Results

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Influenza and pneumonia are major causes of illness and death. In 2005, these conditions ranked as the eighth leading cause of death in the United States and the sixth leading cause in people over 65 years of age (American Lung Association, 2008). Influenza and pneumonia are most likely to require hospitalization in those over 65 years of age. Data from 2005 shows that persons aged 65 and older accounted for 60 percent of the total number of pneumonia hospital discharges and the diagnosis made upon leaving a hospital stay (American Lung Association, 2008). The number (36,000) and rate (9.8 per 10,000 persons) of influenza discharges were both highest in those 65 years and older (American Lung Association, 2008).

Significance of Clinical Problem

The literature review shows the significance of Influenza and vaccination in the elderly.  According to Hak, Hoes, and Verheij (2002), yearly applications of the influenza vaccine (in autumn) can reduce severe complications from influenza among persons aged 65 years or older by 30-60%. In addition, they state that vaccination of older residents of long-term care facilities and their personnel leads to a 42% reduction in mortality rates. The literature review also revealed that risk factors for severe post-influenza complications  include the following:  immune-related factors (e.g., aging or the presence of immune-suppression), respiratory tract disease, proneness to exacerbation of concomitant high-risk disease, adverse effects associated with long-term drug use, or residence in closed communities with high transmission rate (Hak, Hoes, & Verheij, 2002).

It appears, based on the literature review, that pneumonia can be prevented with relative success by resorting to periodic flu vaccinations among people aged 65 and higher. On this point, it is important to point out the fact that this population faces the highest risk of contracting pneumonia, so finding ways of decreasing incidence among them is a top priority. It appears that flu vaccination is a solution; is pneumonia incidence lower on patients aged 65 and higher who have been vaccinated?

PICO Question with all PICO Components

Do patients aged 65 and higher have lower incidence of contracting pneumonia when vaccinated against the flue in the 6-12 months following the vaccination (relative to those who have not been vaccinated)?

P (population/problem). The sample population being considered for the study is comprised of elderly individuals (male and female) aged 65 and higher. Furthermore, there is a problem that is common to the entire population: pneumonia.

I (intervention). The idea behind the intervention is reducing the incidence of pneumonia among the sample population (people aged 65 and higher). Based on the literature review conducted, the proposed intervention is a flu vaccination.

C (comparison). In order to determine the relative effectiveness of the proposed intervention, the projects intends to compare the evolution of pneumonia incidence in the 6-12 months following the flu vaccination (applied to the experimental sample) with the incidence of the control population (who have not been vaccinated) during that period.

O (outcome). The intended outcome of the project is to find a way of effectively reducing the incidence rate of pneumonia among the 65+ population. In a word, the outcome should make it possible to minimize the risk of pneumonia among the elderly.

T (time). The project will take 6-12 months, which is the time that will be allowed to elapse in order to determine if the flu vaccination has succeeded in reducing the incidence of pneumonia among the elderly.

EBP Investigation Process

Selection Criteria

Prior to initiating the search of best evidence for the realization of the project, the first criterion was that evidence had to focus on elderly population (aged 65 and higher). Second, the chosen studies had to consist on an examination of a patient disease (including its treatment and follow up to determine any changes in incidence). In other words, the search was directed at studies that dealt with a research process that intended to find effective treatment options for a particular disease (among the elderly). Third, the search was directed at studies that made comparative analysis between an experimental group and a control group (so as to be able to determine if the proposed treatment was in fact effective).

Search Process

The search was conducted in such a way as to guarantee the highest levels of evidence; systematic reviews, meta-analyses and randomized controlled trials were sought. Randomized controlled (experimental) trials were preferred as they were the most effective in enabling the project to reach its desired outcome (given that they were founded on comparative analysis between experimental and control groups). The CINAHL database was used for conducting the research; Pub Med was also used for research. In the end, 14 articles were preselected for review; 5 were finally chosen for the project. The 14 articles were obtained key terms such as elderly, influenza vaccine, and pneumonia for the CINAHL database. In Pub Med, key terms used were as follows: pneumonia in elderly, influenza vaccine, efficacy, and prevention and control. Limiters used during the research included the following: randomized controlled trials; humans; 65 years and above; English language; abstracts; full-text; free full-texts with abstracts.  Eventually, it was possible to extract six studies that focused on studying the effect of influenza vaccination on pneumonia incidence among the elderly (aged 65 and higher).

Selection of Best Evidence

In an attempt to consider all aspects of the problem at hand, the search was conducted in such a way that it would be possible to articulate a meta-analysis. This being said, a research study conducted by Gross and Hermogenes (1995) was chosen precisely because it too was a meta-analysis comprised of cohort observational studies, case-control studies, cost-effectiveness studies, and a randomized, double-blind, placebo-controlled trial. It is also worth noting that meta-analysis was chosen as it thoroughly examined a number of valid studies on the outcome of flu vaccination in elderly and combined the results using accepted statistical methodology.

Secondly, the process also intended to compile research that aimed at determining the effectiveness of vaccines on elderly populations. This prompted the selection of a study conducted by Puig-Barberà, Diez-Domingo, Pérez Hoyos, Belenguer Varea, and González Vidal (2004). The other three studies that were selected, Mangtani et. al (2004), Nichol, Margolis, and Wuorema (1996; 1994) were chosen because they too focused on examining the effectiveness of vaccine treatments on elderly persons at risk of contracting influenza, pneumonia, or other respiratory illnesses. In the end, the project was realized with five studies (that included cohort, observational, and control studies) that allowed for a comprehensive meta-analysis for the subsequent proposed intervention. Finally, it is worth noting that the aforementioned studies were the only ones finally used as they were the only that conformed to the evidence requirements of the proposed project (they focused on subjects aged 6 and higher, and they attempted to determine the effectiveness of flu vaccination in decreasing pneumonia and other respiratory illnesses’ incidence).

Critical Appraisal of Collective Evidence

In critically appraising the evidence that was compiled for the realization of the project, the first thing that must be said is that it is the result of cohort and control-based studies. This is an advantage given that it provides information that is relevant to the PICO question proposed for this study. The studies focus on the elderly (ages 65 and higher), the intervention proposed in each one is consistent with finding if flu vaccination is efficient with decreasing pneumonia incidence rates, comparative analysis is made between those vaccinated and those not vaccinated (in the control-based studies), and the outcome is homogeneous: flu vaccinations are efficient. Aside from this, it is equally important to point out that the evidence gains in terms of reliability and validity given the size of the study populations (ranging between 20,000 and 40,000) and the fact that the studies have been replicated periodically (once a year, between 1990 and 1993). The only shortcoming is that for the most part the studies were conducted 20 years ago; it would be best to have more recent data given that trends in morbidity change over time.

In terms of the applicability of the selected evidence, it must be said that the five studies offer evidence that is consistent (and therefore applicable) with the clinical question in terms of its PICO components. As it was already mentioned, all studies focus on the elderly; cohorts are comprised of individuals (male and female) aged 65 and higher. Furthermore, all studies are concerned with determining whether or not influenza vaccinations are an effective method of decreasing the incidence of pneumonia and other respiratory illnesses among the elderly. Despite the fact that not all of the studies are control-based experiments, there is sufficient evidence to demonstrate that influenza vaccinations are in fact effective (as comparative analysis does yield that incidence is lower among those who have been vaccinated). Finally, the outcome in all studies is consistent with the desired outcome of the proposed EBP research: decreased incidence through influenza vaccine application.

In terms of sufficiency, it becomes clear that despite the five studies making up for a comprehensive, in-depth analysis of the subject matter, more is needed in order to maintain the information current. Here again it is important to point out that the bulk of the evidence collected was developed in the early 1990s; it is important to replicate these studies today in order to determine what, if anything, has changed in determining the efficiency of influenza vaccines. Notwithstanding this shortcoming, the information compiled from the research is complete insomuch as it accurately describes the sample populations, the risks of pneumonia and influenza (as well as those associated with foregoing vaccination in old age).

Collective Results

One case-control study showed that the risk of hospitalization after the start of the influenza season was significantly lower in vaccinated patients compared with non-vaccinated patients (Puig-Barberà, Diez-Domingo, Pérez Hoyos, Belenguer Varea, and González Vidal, 2004). Second, a cohort study concluded that the risk of hospitalization after the start of the influenza season was significantly lower in vaccinated patients compared with non-vaccinated patients (Mangtani et al., 2004). These results are further complemented by the randomized clinical trials reviewed in the meta-analysis conducted by Gross and Hermogenes (1995), which provided the strongest evidence for the clinical question as they concluded that vaccination reduces the risk of pneumonia, hospitalization, and death. Finally, using database research, Nichol, Margolis, Wuorema, and Von Sternberg (1996; 1994) concluded based on their studies of 25,000 elderly people cohorts (ages 65 and higher) that vaccination against influenza is positively with reduction of hospitalization, death, and other respiratory complications. They also

Based on these results, it becomes clear that during an influenza outbreak/epidemic, vaccines constitute the most effective way of keeping incidence rates down. Furthermore, it becomes clear that is important to exert greater efforts in promoting vaccination campaigns for the elderly as they are the ones facing higher risks (not to mention the fact that the majority of those studied reported either not being vaccinated or not recalling if they had been vaccinated). In order to more effectively combat influenza and pneumonia, it is imperative that programs be designed to vaccinate as many individuals as possible; it is equally important that vaccinations be performed on a yearly basis prior to the beginning of seasonal outbreaks.

Intervention Decision

In terms of implications for practice, it becomes clear that the EBP inquiry conducted evidenced a need to promote influenza vaccination programs for the elderly (aged 65 and higher), especially during influenza outbreak seasons. Furthermore, given that individuals aged 65 and higher face greater risks of contracting respiratory diseases such as influenza and pneumonia, it is important that such programs be renewed on a yearly basis so as to decrease incidence rates (and financial costs associated with medical service). The proposed intervention (vaccination of elderly people in order to bring pneumonia incidence rates down) is clearly supported by the EBP inquiry.

However, it is important that such efforts be focused only on the most vulnerable population, the elderly (specifically those residing in areas where influenza outbreaks are frequent). In order to do this, the Iowa Model of Evidence-Based Practice could be applied. First, further research would have to be conducted in order to corroborate the previously analyzed research. Second, a team would be formed to promote a change in the way in which influenza and respiratory illness is dealt with. Finally, once a program that promotes periodic influenza vaccination (on an annual basis) is consolidated, the information should be disseminated so that the program could be replicated in all areas where there are vulnerable populations. Of course, realizing the project would depend on the availability of staff and equipment (namely needles, antiseptic, and vaccines) readily available; the resources available would have to be administered as effectively as possible (meaning that only those facing highest risks should be vaccinated in case not everyone can).

Plan for Implementation and Evaluation of Intervention Decision

In order to successfully implement an Evidence-based intervention in clinical practice, the first thing that would be needed would be complete segmentation of the population. It is important to know how many individuals (ages 65 and higher) reside in the community/area that will be targeted. In the state of Iowa, for example, the total population (aged 65 and higher) ascends to 452,888 (based on the 2010 census); using a 5% sample the intervention could be initially applied on 22,644 men and women aged 65 or higher. The intervention would basically consist on dividing the sample population in two groups (experimental and control); only the experimental group would receive the influenza vaccine. In the following 6-12 months, a follow-up on respiratory illness hospitalization and death would be conducted periodically (it would be recommended that data be collected on a monthly basis starting on the sixth month) so as to determine whether or not the intervention was effective.

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