Optimizing Education to Improve COVID-19 Vaccination Rates in a Federally Qualified Health Center.

INTRODUCTION: COVID-19 vaccination hesitancy is prevalent in underserved communities, and family medicine clinics can combat hesitancy with vaccine education. However, due to general misinformation, physicians hesitate to educate patients because doing so can create conflict. METHODS: A series of resident-run, team-based quality improvement projects were conducted at a federally qualified health center every 4 months between June 2021 and May 2022. First, staff documentation of vaccine status was addressed. Second, physician and staff education about COVID-19 vaccines was completed along with motivational interview training to avoid conflict with patients. Third, patient COVID-19 vaccine education was addressed. RESULTS: After Cycle 1, COVID-19 vaccine documentation status increased the number of patients who completed the vaccination series from 1% to 22%. Cycle 2 showed an increase in COVID-19 vaccination rate after health care team education. This reflected an increase from 35% to 76% of residents reporting that they discussed COVID-19 vaccines with unvaccinated patients after the intervention. Cycle 3 fought vaccine misinformation by educating patients. Most patients heard information about COVID-19 vaccines from friends and family (95%), social media (90%), and the news (80%). Physician confidence in providing COVID-19 vaccine education to patients increased from 2.8 (< somewhat confident) to 4.3 (moderately confident) out of 5 over 3 plan-do-study-act cycles. DISCUSSION: Vaccination rates were tracked alongside physician surveys regarding the experience of offering the vaccine to patients. Vaccination rates steadily increased over time, and physicians became more confident in COVID-19 vaccine discussions with patients. CONCLUSION: Primary care physicians are needed to approach public health concerns, such as vaccination completion, but ongoing education is also needed to promote confidence in health care pathways.

Respiratory Symptom Evaluation in Adults: Chronic Cough.

In adults, chronic cough is a nonproductive or productive cough lasting longer than 8 weeks. Coughing is a reflex to clear the lungs and airways, but repetitive, long-term coughing can cause chronic irritation and inflammation. Approximately 90% of chronic cough diagnoses have common nonmalignant etiologies, including upper airway cough syndrome, asthma, gastroesophageal reflux disease, and nonasthmatic eosinophilic bronchitis. In addition to history and physical examination, initial evaluation for chronic cough includes pulmonary function testing and chest x-ray to assess the lungs and heart and for fluid overload, and evaluate for neoplasm or lymph node enlargement. If the patient has red flag symptoms, such as fever, weight loss, hemoptysis, or recurrent pneumonia, or has persistent symptoms despite optimal drug treatment, advanced imaging with chest computed tomography scan is indicated. Management of chronic cough includes identifying and managing the underlying cause as outlined in the American College of Chest Physicians (CHEST) and European Respiratory Society (ERS) guidelines for chronic cough. In diagnoses of refractory chronic cough with uncertain etiology and a negative evaluation for life-threatening causes, cough hypersensitivity syndrome should be considered and managed with gabapentin or pregabalin and a trial of speech therapy.

Respiratory Symptom Evaluation in Adults: Wheezing.

Wheezing is a common presenting concern in the primary care setting, but its etiology can be elusive. Wheezing is associated with many disease processes, but most commonly, asthma and chronic obstructive pulmonary disease. Initial tests for wheezing typically include a chest x-ray and pulmonary function testing with bronchodilator challenge. Advanced imaging to evaluate for malignancy should be considered in patients older than 40 years with a significant history of tobacco use and new-onset wheezing. A trial of short-acting beta agonists can be considered while awaiting formal evaluation. Because wheezing is associated with reduced quality of life and increased health care costs, it is essential to develop a standardized evaluation of this common concern and expeditiously manage symptoms.

Respiratory Symptom Evaluation in Adults: Dyspnea.

Dyspnea is a common presenting symptom that may derive from pulmonary or extrapulmonary origins. Dyspnea may develop from exposure to drugs or environmental and occupational factors, so a thorough history and physical examination may help differentiate the cause. Chest x-ray followed by chest computed tomography scan if needed is recommended as the initial imaging test for pulmonary-related dyspnea. Nonpharmacotherapy options include supplemental oxygen, self-management with breathing exercises, and airway interventions with rapid sequence intubation in emergency situations. Pharmacotherapy options include opioids, benzodiazepines, corticosteroids, and bronchodilators. After the diagnosis is identified, treatment focuses on optimizing dyspnea symptoms. Prognosis depends on the underlying condition.

Respiratory Symptom Evaluation in Adults: Hemoptysis.

Hemoptysis is the expectoration of blood from the lower respiratory tract and has an extensive differential diagnosis that can be divided into pseudohemoptysis, infectious, neoplastic, vascular, autoimmune, and drug-related categories. Pseudohemoptysis is the expectoration of blood from a different source and needs to be ruled out. Clinical and hemodynamic stability must be established first. Chest x-ray is the initial imaging examination for all patients with hemoptysis. However, advanced imaging, such as a computed tomography scan, is helpful for further evaluation. Management aims to ensure patient stabilization. Most diagnoses are self-limited, but bronchoscopy and transarterial bronchial artery embolization can be used to manage massive hemoptysis.