469 - Flu Vaccine 2022-23, Contextualizing Care, Ready … or Not?

From the Advisory Committee on Immunization Practices and CDC

1)    Influenza vaccines for 2022-3

It’s time to think about influenza again. The traditional flu season is October 1st through April 30th, and after a brief respite in 2020-21 due to COVID-19, influenza was prevalent last year, and looks to be starting a bit early this year. In the first week of monitoring in Virginia this year, 3.2% of the ED and urgent care visits were for “influenza-like illness (ILI),” which is the usual clinical way to monitor flu. This is the highest starting percentage in the last 4 years.

In terms of influenza vaccine, the notable news is that for the first time, the ACIP has found sufficient evidence to preferentially recommend the high-dose influenza vaccination for people aged 65 and over. The evidence was by no means clear cut – but the ACIP felt that enough benefit (reduction in ILI, one study showing decrease influenza death) existed to make the recommendation.

Other main points from this year’s recommendation:

·         Influenza vaccine is (still) recommended for everyone, age 6 months and older.

·         All vaccines are quadrivalent this year, with two strains of flu A and two of flu B.

·         There is no preference for any other type of influenza vaccine – inactivated, recombinant, or live attenuated.

·         It is best to get the flu shot in September or October, so that the immunity does not wane prior to the end of influenza season. It is recommended to continue influenza vaccination beyond October as long as there is circulating flu and vaccine supplies hold out.

·         Children aged 6 months to 8 years need two doses (separated by a month) if they have never received any influenza vaccine previously.

·         Pregnant persons are encouraged to get the influenza vaccine in the third trimester to protect themselves and their newborns after delivery.

·         COVID-19 vaccines can be given at the same time as flu vaccines.

·         Guillain-Barre syndrome after previous influenza vaccine is a precaution (not necessarily a contraindication) to flu vaccine, but if the patient is at low risk for influenza complications, not vaccinating them is reasonable.

·         Egg allergy – Flublok (RIV4) and Flucelvax (ccIIV4) do not have egg proteins. If the previous reaction to eggs was simply hives, it is Ok to get any flu vaccine. If the previous reaction was more serious (angioedema, etc.), then vaccination with any egg-based vaccine should occur in a medical setting.

·         Vaccine allergy – Any previous severe allergy (i.e., anaphylaxis) to an egg-based flu vaccine is a contraindication to any other egg-based flu vaccine and is a precaution for RIV4 and ccIIV4. Anaphylaxis to either RIV4 or ccIIV4 is a contraindication to each of those vaccines, respectively.

·         Live attenuated influenza vaccine (LAIV) has a list of precautions and contraindications because it is a live virus – see the reference below for information.

John’s Comments:

Despite having been overshadowed by COVID-19 for the past couple of years, flu is still an important cause of morbidity and mortality in the most vulnerable in our population: the very young, the very old and those with chronic disease and immune compromise. Keep consistently and patiently encouraging flu shots for your patients!

Reference:

Grohskopf LA. Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2022–23 Influenza Season. MMWR Recomm Rep. 2022;71. Link

From the Literature

2)    Incorporating a Patient’s Context Into Clinical Care

Clinical decision making can be described as the complex and dynamic process of integrating multiple types of information, including a patient’s clinical state, the research evidence for managing their clinical state, the clinician’s experience, the patient’s preferences and the patient’s context, into their care. Patient context refers to the life circumstances and patient behaviors relevant to planning a particular patient’s care.

When a clinician fails to elicit or disregards patient context, an otherwise seemingly appropriate care plan, based on the clinical state and research evidence, can result in an unintended and/or undesirable outcome and is therefore inappropriate for that patient. Such an omission is called a contextual error, which is a subtype of medical error in that it constitutes the “…use of a wrong plan to achieve an aim.”

There are clues, referred to as “contextual red flags, that suggest that a patient may be struggling with a life situation that is negatively impacting or complicating their care.

These clues include patient behaviors such as missed appointments or not refilling medications, changes in the status of a chronic condition such as loss of blood pressure control, or patient utterances during a medical encounter such as “Boy, it’s been tough since I lost my job.” If contextual red flags are identified, the next step would be to inquire more about them, a process known as “contextual probing.” For example: “Ms. Davis, I notice that your blood sugar has been unusually high lately. Is something going on that is making it more difficult for you manage your diabetes?”

The third step is clarifying the patient’s response to ascertain whether there are in fact challenges or “contextual factors” that are complicating their care. Contextual factors can be grouped in 12 domains.

-  Access to Care                               - Skills, Abilities, and Knowledge

-  Competing Responsibilities         - Emotional State

-  Social Support                                - Cultural Perspective/Spiritual Beliefs

-  Financial Situation                        - Attitude Toward Illness

-  Environment                                   - Attitude Toward Clinician and System

-  Resources                                      - Health Behavior

These can serve as a type of “differential” for the clinician when attempting to identify the relevant patient context that may need to be addressed in order to customize a care plan that will achieve the desired aims.

Finally, when contextual factors are revealed, the fourth step is to take these factors into account as part of the clinical decision-making process – to “contextualize the care.”

The linear process would look like this: Contextual red flag → Contextual probe → contextual factors → contextualized care plan.

Mark’s Comments:

Let’s face it. The practice of clinical medicine, particularly for those with multiple chronic diseases, is much more complex than it is often portrayed to be. Clinicians must be skilled in obtaining all available and relevant information in order to provide optimal patient care.  Understanding and integrating an individuals’ context elevates the clinician from being a technician to being a healer and a true medical “artist.” Doing so can often be quite frustrating when all the barriers our patient’s face to improving their health are exposed, and certainly creates the “temptation” to take the pathway of least resistance and ignore or minimize the importance of patient context.

With that in mind, it’s helpful to know what resources are available in your community to help support the care you are providing, and also to remember the wisdom of doing the best you can with what you have from where you are, always with some added kindness and compassion for good measure – both to your patients AND to yourself.

Reference:

Adapted from Weiner, S. Contextualizing care: An essential and measurable clinical competency. Patient Education and Counseling. Vol 105, Issue 3, March 2022: 594-

598. Link

From PeerRxMed ( www.PeerRxMed.org )

3)    Ready … or Not? Stop “Shoulding” on Yourself

Next time you feel a should coming at you, ask yourself if it really belongs to you!” ― Kelly Corbet, author of BIG: The Practice of Joy

In last week’s blog, we began the journey of trying to understand why it is often so difficult to travel “the longest yard” – the distance between our knowledge (head), our beliefs (heart) and our action (hands).

A common tendency when it comes to behavior change is to believe that thinking we “should” or “should want” to do something provides motivation. Sometimes it even comes disguised with a greater sense of urgency by substituting the words “need to” for “should.” For example, I recognize that I should learn to say “no” more often, to both professional opportunities and cookies, but for reasons that I often credit as “beyond me,” I don’t. Frequently I’ll have a patient tell me they “need” to exercise or “should” lose weight, but they also don’t. In both cases, I have come to understand that the “culprit” is often not a lack of discipline or impulse control, but rather that we’re simply just not ready to make the change.

The Behavioral Sciences explain this dynamic through the Transtheoretical Model (TTM), otherwise known as the “Stages of Change.” This model proposes that most sustainable behavior change is a process, and the first step of that process is determining whether one even wants to make that change (going from “precontemplation” to “contemplation”), and if so, beginning a very deliberate planning process (“preparation”) before moving to “action” and “maintenance.” This model also acknowledges that any change process will likely have slip-ups (“relapses”), necessitating for one to reenter at some point in the process once again.

In other words, we change when we’re ready to change, and not a moment before. The technique of Motivational Interviewing or “change talk” has therefore been developed help both identify whether someone is motivated for behavior change, and if not, how to help them (or us) gain the insights that might help progression along the stages of change. It assesses the degree of importance (do I want to?) of any change as well as the confidence that it can be achieved (can I?), and determines what would be required to elevate both – recognizing that it is only when someone is both willing and able that they are truly ready for any particular change.

Consider those areas where you are presently feeling “stuck.” Is it possible that the reason change is not happening is that you’re lacking in “will” or “skill”? In my own example, I’m realizing that I generally like all that I’m presently doing, and I sure do enjoy a good cookie. However, in both cases I have recently detected a shift in me from “should” change (“contemplation”) to “will” change (perhaps one cookie is enough), so it appears the time has arrived to prepare for action. Afterall, when it comes to getting unstuck, it seems like sanity to apply the best of what we know about behavior change to help get us there. Spoiler alert – it will include your PeerRx partner and other support

… no “shoulds” about it.

Next week we’ll look at how the “elephant” in your life may be sabotaging your change success, and will explore some strategies to help guide that elephant down your desired path.

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org