Offering Free Vaccination Eliminates Disparities in Adult Immunization But Low Cost Vaccination Does Not Free vs. Cheap Daniel B. Fishbein, William B. Cassidy, Dale Bell Marioneaux, Monica Pradhan, Mark Messonnier, Doug Schwalm, Noelle-Angelique

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Offering Free Vaccination Eliminates Disparities
in Adult Immunization But Low Cost Vaccination
Does NotFree vs. CheapDaniel B. Fishbein,
William B. Cassidy, Dale Bell Marioneaux, Monica
Pradhan, Mark Messonnier, Doug Schwalm,
Noelle-Angelique Molinari, Carla Winston
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Collaborators
NVPO

• CDC
• Bayo Willis
• Edith Gary
• Pascale Wortley
• Mary McCauley
• Ronald Nuse
• Task Force on Community Preventive Services

• LSU
• Pam Saloom
• Glenn Jones
• Kim Nguyen
• Larie Witt
• Cathy Henderson
• J. Nelson Perrett
• Sara DAutramont

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Institute of Medicine

• Priorities should shift from documenting
  disparities to assessing interventions strategies
  ..that separate the contribution of the patient,
  provider, and institution.
• Unequal Treatment
• Institute of Medicine 2002

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Outline

• Why do disparities exist?
• Study 1 Separating the contribution of the
  provider in family practice clinics
• Study 2 Separating the contribution of the
  provider II Move to emergency rooms
• Study 3 Separate the contribution of the
  institution Financial disincentives
• Conclusions

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Outline

• Why do disparities exist?
• Study 1 Separating the contribution of the
  provider in family practice clinics
• Study 2 Separating the contribution of the
  provider II
• Study 3 Separate the contribution of the
  institution Financial disincentives
• Conclusions

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Racial and Ethnic Disparities

• The conditions in which many clinical encounters
  take place, characterized by high time pressure,
  cognitive complexity, and pressures for cost
  containment may enhance the likelihood (of)
  care poorly matched to minority patients needs
• Unequal Treatment
• Institute of Medicine 2002

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Time Constraints
To fully satisfy the USPSTF recommendations,
1774 hours of physicians annual time, or 7.4
hours per working day, is needed for the
provision of preventive services.
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Outline

• Why do disparities exist?
• Study 1 Separating the contribution of the
  provider I in family practice clinics
• Study 2 Separating the contribution of the
  provider II
• Study 3 Separate the contribution of the
  institution Financial disincentives
• Conclusions

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Assessment-Reminder (A/R) Tool

• Assess patients vaccination needs
• Self- or assisted-administration
• Reminds patient and provider about indicated
  vaccinations

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Separating the Contribution of the Provider I
Family Practice Clinics

• Setting
• Sample and design
• Intervention
• Outcome measures

• Three family practice clinics, interested
  physicians, diverse patient populations, many
  safety nets for vaccination
• Convenience sample of 100 intervention and 100
  control patients at each clinic
• Assessment reminder form (6 vaccines) versus
  exercise promotion
• Vaccinations according to chart review

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Efficacy of A/R Tool
Indicated refers to being at risk (having
vaccine specific risk factor) and not being up
to date based on medical record review
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Outline

• Why do disparities exist?
• Study 1 Separating the contribution of the
  provider I Family practice clinics
• Study 2 Separating the contribution of the
  provider II Move to emergency rooms
• Study 3 Separate the contribution of the
  institution Financial disincentives
• Conclusions

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Why Emergency Departments?

• Easier place for us to separate the contribution
  of the patient, provider, and institution
• Providers primarily focused on the chief
  complaint and willing to let us focus on
  prevention
• Patients who are not critically ill have plenty
  of time

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Why Emergency Departments?

• People who seek primary care in emergency
  departments ideal target group
• More likely to be underinsured and therefore
  under vaccinated
• Efficiency
• Have time while waiting in ED, but not during the
  rest of their lives

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Trend in Emergency Department Visit Rates United
States, 1992-2001
NOTE Trend is significant (plt0.05).
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Emergency Department Visits By Age And Race
United States, 2001

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Moving To Emergency Rooms Is Every Visit a
Missed Opportunity to Vaccinate?

• Setting
• Sample and design
• Intervention
• Outcome measure

• Urban emergency department, almost all patients
  low income, October 2003
• Convenience sample of 104 patients randomized to
  vaccination in the ED versus referral for
  vaccination
• Assessment reminder form (3 vaccines) and
  standing order
• Vaccination

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Assessment-Reminder Tool Urban Emergency Room
vs. Clinic
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Assessment-Reminder Tool Urban Emergency Room
vs. Clinic
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Outline

• Why do disparities exist?
• Study 1 Separating the contribution of the
  provider I Family practice clinics
• Study 2 Separating the contribution of the
  provider II Move to emergency rooms
• Study 3 Separate the contribution of the
  institution Financial disincentives
• Conclusions

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Separate the contribution of the institution
Financial disincentives Willingness to Pay For
Vaccinations

• Setting
• Sample and design
• Data
• Outcome

• Urban emergency department, mix of low and middle
  income, many minority, December 2003-January 2004
• 600 consecutive patients 18-64 years, assessed by
  college students, randomized to free vaccine, 5
  per shot, or 10 per shot (200 per group)
• Assessment reminder form
• Acceptance of vaccination

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Demographic Characteristics, By Randomization
Status
Characteristic 0 (n202) 5 (n200) 10 (n198)
Age, mean (SE) 37.3 (0.94) 38.9 (0.91) 35.8 (0.89)
18-49 77 (156) 74 (147) 83 (164)
Gender, female 58 (118) 55 (108) 61 (120)
Race, black 79 (159) 77 (153) 81 (160)
Incomelt1000/m 41 (75) 43 (79) 47 (84)
Insurance, private 51 (96) 50 (94) 43 (77)
Medicaid 26 (51) 24 (48) 30 (58)
plt0.05 compared to 5 group
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Selected Characteristics, by Race
Characteristic Black (n469) Non-black (n124) P
Age, 18-49 82 (383) 65 (80) lt0.0001
Gender, female 60 (280) 51 (63) NS
Incomelt1000/mo 49 (206) 22 (24) lt0.0001
Insurance, private 43 (190) 70 (80) lt0.0001
Medicaid 28 (127) 17 (48) 0.02
Most white but included 7 others 7 missing
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Statistically significant Associations with
Acceptance of Vaccine in the ED

• Univariate analysis

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Vaccine Receipt, By Cost
2010 Target
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Vaccine Receipt, By Cost
2010 Target
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Vaccine Receipt, By Cost
2010 Target
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Vaccine Receipt, By Cost
2010 Target
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Vaccine Receipt, By Cost
2010 Target
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Vaccine Receipt, By Race
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Vaccine Receipt, By Race
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Vaccine Receipt, By Race
P0.003 Chi square
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Accepted Influenza Vaccination, Logistic
Regression
Variable OR 95 CI P
Cost, free Ref
5 0.19 0.09-0.40 lt0.001
10 0.14 0.07-0.29 lt0.001
Not significant age, gender, race, Medicaid,
income, private insurance,
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Accepted Pneumococcal Vaccination, Logistic
Regression
Variable OR 95 CI P
Cost, free Ref
5 0.08 0.02-0.38 0.001
10 0.03 0.01-0.15 lt0.001
Race, non-black Ref
black 0.19 0.05-0.72 0.015
Controlling for age, gender, income, private
insurance, Medicaid
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Accepted Hepatitis B Vaccination, Logistic
Regression
Variable OR 95 CI P
Cost, free Ref
5 0.13 0.03-0.55 0.006
10 0.13 0.04-0.47 0.002
Controlling for age, gender, race, income,
Medicaid, private insurance
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Cost Analysis

• Total cost
• Screening, administration, vaccine
• Influenza 17.72
• Pneumococcal 28.23
• Hepatitis B 28.45

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Cost Analysis

• Supplies (excluding vaccine) 7.49
• Labor
  3.33
• Screening, college students (4.8 min)
• Review and sign order, MD (22 sec.)
• Administration, RN (5.6 minutes)
• Vaccines
• Influenza 6.90
• Pneumococcal 17.41
• Hepatitis B 17.63

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Outline

• Why do disparities exist?
• Study 1 Separating the contribution of the
  provider I Family practice clinics
• Study 2 Separating the contribution of the
  provider II Move to emergency rooms
• Study 3 Separate the contribution of the
  institution Financial disincentives
• Conclusions

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Conclusion 1 By ED Physician

• Everybody wants something for free

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Conclusion 2

• By using the A/R form and offering free
  vaccination in the ED, we were able to overcome
  many barriers to adult immunization
• By offering free vaccination in the ED, we were
  able to increase coverage of influenza and
  pneumococcal vaccines to levels that exceeded
  2010 targets

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Conclusion 3

• Offering free vaccination eliminates disparities
  in adult immunization but low cost vaccination
  does not
• Many patients, including those with insurance,
  may be unwilling to pay for immunizations
• Unless we address out of pocket costs of
  immunizations, we may be unable to meet our 2010
  targets

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Development as FreedomAmartya Sen, 1999

• ..being relatively poor in a rich country can
  be a great handicap even when that person is at
  a much higher level of income compared with
  people in less opulent countries.

Development as Freedom Amartya Sen, 1999
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