Improving Immunization Rates For Seniors in Long-Term Care: The CDC/CMS Immunization Standing Orders Project

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Improving Immunization Rates For Seniors in
Long-Term CareThe CDC/CMS Immunization
Standing Orders Project

• Dale W. Bratzler, DO, MPH
• Principal Clinical Coordinator
• Oklahoma Foundation for Medical Quality, Inc.

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Documented Influenza and Pneumococcal
Vaccination, 1995-1999
National Nursing Home Survey
Buikema AR, Singleton JA, et al. abstract
Centers for Disease Control and Prevention, 35th
National Immunization Conference.
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Vaccination Reality

• Despite the fact that the influenza and
  pneumococcal vaccines are
• clinically effective
• cost effective
• safe
• free to most elderly patients
• Healthy People 2010 goals of 90 vaccination
  rates

They are underutilized!
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The CDC/CMS Immunization Standing Orders Project

• Collaborative effort between the Centers for
  Disease Control and Prevention (CDC) and the
  Centers for Medicare Medicaid Services (CMS)
• Measurement and intervention implemented through
  the Medicare QIO Program (formerly, Peer Review
  Organizations)

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SOP Steering Committee

• CDC
• Abigail Shefer (PI)
• Linda McKibben (Co-PI)
• Paul Stange
• OFMQ
• Dale Bratzler
• Jennifer OHagan
• Lori Moore
• Kathy Hankey

• CMS
• Jackie Harley
• Kathy Pirotte
• Peter Houck
• QIO Representative
• Kurt Stevenson

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Overall Goal of the SOP

• To increase coverage rates for pneumococcal and
  influenza vaccines in long-term care facilities
  through the use of standing orders programs

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Standing Orders Programs

• Standing orders programs authorize nurses or
  pharmacists to administer vaccinations according
  to an institution- or physician-approved protocol
  without a physicians examination

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Standing Orders Project Methods

• Short survey (N 2,065)
• 20 LTCs in each state (N 280)
• Based on facility size, influenza program type,
  and QIO participation
• Long survey and coverage data completed at same
  facilities
• Cost survey completed in a subset

Not used for selection in control States
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Vaccination CoverageSOP Project, Baseline
2000-2001
N 277 LTCs (21,624 residents)
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Vaccination Policies and Procedures for Residents
N 249 LTCs, Long Survey
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Vaccination Policies and Procedures for Staff
N 249 LTCs, Long Survey
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Barriers to Immunizing Residents
N 249 LTCs, Long Survey
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Barriers to Implementing Standing Order Programs
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Tracking and Documentation of Vaccination
N 249 LTCs, Long Survey
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Immunization Program TypesSurvey Definitions

• Usual Care - individual physician order
• Reminders (R/R) - remind physician or residents
• Preprinted Admission Order (PPAO) - Standardized
  forms placed in chart for physician signature
• Advanced Physician Order (APO) - physician
  authorizes vaccination of their patients
• Standing Order (SOP) - authorizes immunization of
  all residents by institutional policy

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Type of Immunization ProgramShort Survey
N 1,598 LTCs in 7 intervention states with
complete survey and OSCAR data
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Flu Program Type and CoverageLong Survey and
Coverage Data (N 249)
coverage
Usual (n53)
APO (n35)
PPAO (n58)
R/R (n57)
SOP (n44)
Program Type
Median and 25/75 percentile
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Pneumococcal Program Type and Coverage (N 249)
coverage
Usual (n118)
APO (n17)
R/R (n52)
PPAO (n36)
SOP (n24)
Program Type
Median and 25/75 percentile
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Influenza Program Cost Estimates, by Activity
Based on 10 observations ?Standard deviations
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Interpretation of Influenza Results Cost Survey
and Coverage
Incremental Effectiveness of SOP compared to
alternative interventions
More
Same
Less
More
Incremental Cost of SOP compared to alternative
interventions
Same
Accept SOP over PPAO, RR, and APO
Less
RTI, International
Strong dominance for acceptance/rejection Weak
dominance for acceptance/rejection No obvious
decision without further analysis
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Vaccination and OutcomesPreliminary data -
hospitalization
Hospital stays with a discharge date between
November 1, 2000, and April 30, 2001.
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Vaccination and OutcomesPreliminary data -
mortality
All-cause mortality between November 1, 2000,
and April 30, 2001.
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Vaccination in Nursing HomesA Unique Opportunity
to Improve

• There are approximately 1.5 million residents
  living in more than 17,000 nursing homes in the
  US
• Preventing adverse events in this population will
  require systems-based interventions to ensure
  quality care

American Health Care Association
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