Where Are We Now 5 Years After the Recommendations from the Task Force on Community Preventive Services?

1
Where Are We Now 5 Years After the
Recommendations from the Task Force on Community
Preventive Services?

• National Immunization Conference
• Washington, D.C.
• March 23, 2005
• Daniel B. Fishbein, M.D.
• Immunization Services Division
• National Immunization Program
• dbf1_at_cdc.gov

2
Outline

• Background
• What did the recommendations of the Task Force on
  Community Preventive Services say?
• What do others evidence-based analyses say?

3
Background
Coverage for adult immunization is a fig leaf,
incomplete, focused on specific areas
A physician trying to begin a community-wide
adult immunization program

4
Background Influenza Vaccination Coverage
HP 2010 Targets
Age gt 64
Age lt 65 in target group
5
What did the recommendations of the Task Force on
Community Preventive Services say?

• Universally recommended vaccines
• Recommended for all or most people in a single
  age group
• Increasing community demand
• Enhancing access to vaccination services
• Provider-based interventions
• Classification
• Strongly recommended
• Recommended
• Insufficient evidence
• Targeted vaccines

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Universally Recommended Vaccines

• Strongly recommended age-based recommendations
  (median coverage increase)
• Increasing community demand
• Client reminder recall (12)
• Multi-component interventions including education
  (16)
• Enhancing access to vaccination services
• Reducing out-of-pocket costs (15)
• Expanding access in health care settings (10)
• Provider-based interventions
• Provider reminder recall (17)
• Assessment and feedback (16)
• Standing orders (adults only) (28)

7
Universally Recommended Vaccines

• Recommended
• Increasing community demand
• Vaccination requirements for childcare, school,
  and college attendance (15)
• Enhancing access to vaccination services
• Vaccination programs in WIC settings
• Home visits (10)
• Vaccination programs in schools

8
Universally Recommended Vaccines

• Insufficient Evidence
• Increasing community demand
• Community-wide education only
• Clinic based education-only interventions
• Client held medical records
• Clinic-based education (3)
• Client or family incentives
• Enhancing access to vaccination services
• Vaccination in childcare centers
• Provider-based interventions
• Provider education

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Outline

• What did The Guide say about immunizations?
• What did others evidence-based analyses say about
  immunization?

10
All Interventions Are Not Created Equal
11
What Do Others Evidence-based Analyses Say?
Intervention component Adjusted OR (95 CI)
Organizational change 16.0 (11.2-22.8)
Provider reminder 3.8 (3.3-4.4)
Patient financial incentive 3.4 (2.9-4.4)
Provider education 3.2 (2.2-4.6)
Patient reminder 2.5 (2.2-2.8)
Patient education 1.3 (1.1-1.5)
Adapted from Stone EG. Interventions that
increase use of adult immunization and cancer
screening services a meta-analysis. Ann Intern
Med 2002 136641-651. Prevention clinics and
visits, designate non physician staff for
prevention activities, standing orders NS
patient education, provider financial incentive,
feedback
12
What Do Others Evidence-based Analyses Say?
Intervention component Adjusted OR (95 CI)
Organizational change 16.0 (11.2-22.8)
Adapted from Stone EG. Interventions that
increase use of adult immunization and cancer
screening services a meta-analysis. Ann Intern
Med 2002 136641-651. Prevention clinics and
visits, designate non physician staff for
prevention activities, standing orders Not
significant Patient education, provider
financial incentive, feedback
13
Why Is Organizational Change So Important?
14
Time Required For Primary Care Physicians To
Provide Services Recommended By The U.S.
Preventive Services Task Force
Patient group Hours per physician per day
Adults 4.4
Children and adolescents 2.2
Pregnant women 0.1
High risk groups 0.6
Total 7.4
Yarnall KS. Primary care is there enough time
for prevention? Am J Public Health 2003
93635-641.
15
Structure for the Rest of the Slides

• Intervention
• versus
• Control

16

Baseline
17

After Intervention
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An Organizational ChangeMaking Prevention Easy
for Providers

• Effects of computerized reminders on the rates at
  which four preventive therapies were ordered for
  inpatients
• Randomized, controlled trial
• System processed on-line information for all
  patients admitted to a general-medicine service
• Physicians in the
• Intervention group viewed reminders each time
  they used the computerized order- entry system.
• Control group received no reminder
• Adapted from Dexter PR. A computerized reminder
  system to increase the use of preventive care for
  hospitalized patients. N Engl J Med.
  345965-970, 2001.

19

An Organizational ChangeMaking Prevention Easy
for Providers
Jain G et al. SouthEast Michigan Automaker
Influenza Vaccination Rates by Age, Risk Status
and Vaccine Availability
20
An Organizational ChangeMaking Immunization Even
Easier for Providers

• Randomized, controlled trial
• Compared computerized reminders to computerized
  standing orders on influenza and pneumococcal
  vaccination for inpatients
• System processed on-line information for all
  patients admitted to a general-medicine service
• Computer generated
• standing orders versus
• physicians reminder order- entry system
• Adapted from Dexter PR. Inpatient computer-based
  standing orders versus physician reminders to
  increase influenza vaccination rates.
• JAMA 2004 2922366-71 .

21

Making Vaccination Convenient for
ProvidersSpontanteous
Adapted from Dexter PR. Inpatient computer-based
standing orders versus physician reminders to
increase influenza vaccination rates. JAMA 2004
2922366-71 .
22

Making Vaccination Convenient for ProvidersWith
Intervention
Adapted from Dexter PR. Inpatient computer-based
standing orders versus physician reminders to
increase influenza vaccination rates. JAMA 2004
2922366-71 .
23
Making Vaccination Convenient and Free for
Employees

• Three worksite flu vaccination programs offered
• Insurance coverage all provide coverage for flu
  shots, regardless of health insurance product
  type
• All encourage receipt of the flu shot
• Worksite flu shot programs
• Offsite No access to the flu shot at the
  worksite
• 7 Access at the worksite, with a 7 co-payment
• 0 Access at the worksite at no cost to the
  employee

Adapted from Jain G et al. SouthEast Michigan
Automaker Influenza Vaccination Rates by Age,
Risk Status and Vaccine Availability
24

Making Vaccination Free and Convenient for
Employees
Jain G et al. SouthEast Michigan Automaker
Influenza Vaccination Rates by Age, Risk Status
and Vaccine Availability
25
Making Vaccination Free and Convenient for the
Poor

• Public Hospital Emergency Room in Baton Rouge
  Louisiana, October 2003
• Low income adults lt65 years (no insurance or
  public insurance)
• Screened to see if they were in target group for
  influenza, pneumococcal conjugate, or hepatitis B
  vaccines
• No charge for vaccinations
• Randomized to Delayed (walk-in 2 weeks later) vs.
  Immediate vaccination

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Making Vaccination Free and Convenient for the
PoorBefore Intervention
27
Plt0.00001 P0.045
P0.09
Making Vaccination Free and Convenient for the
Poor After Intervention
28
Making Vaccination Free and Convenient for
Everyone

• Community Hospital Emergency Room in Baton Rouge
  Louisiana, December 2003 January 2004
• Adults lt65 years, various income brackets
• Screened to see if they were in target group for
  influenza, pneumococcal conjugate, or hepatitis B
  vaccines
• Randomized to 10 vs. 5 vs. 0 for each
  indicated vaccination

29

Making Vaccination Free and Convenient for
EveryoneBefore Intervention
three doses
30

Making Vaccination Free for EveryoneAfter
Intervention
Plt0.00001 Plt0.00001
P0.0004 one dose
31
Conclusions

• We need to focus on interventions that make
  vaccination easier for providers and patients
• because it is more convenient
• because it is less expensive

32
Its time to play final jeopardy
33

V F A
Vaccines for Adults
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What is free and convenient?
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References

• Briss P et al. Review of evidence regarding
  interventions to improve vaccination coverage in
  children, adolescents, and adults. Am J Prev Med
  200018 (1S)97-140.
• Coleman M (et al) Estimating Medical Practice
  Expenses from Adult Influenza Vaccinations
• Davis M (et al). Adult Vaccine Benefit Coverage
  in Employer-Sponsored Health Plans. National
  Immunization Conference 2004 (abstract 4906) and
  unpublished data
• Fishbein D (et al). Adult Vaccination in
  Emergency Rooms A Shot at Decreasing Health
  Disparities in the United States? NIC 2004
  (abstract 5485)
• Fontanesi J (et al). Operational conditions
  affecting the vaccination of older adults. Am J
  Prev Med. 2004 May26(4)265-70 and unpublished
  data
• McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J,
  DeCristofaro A et al. The quality of health care
  delivered to adults in the United States. N Engl
  J Med 2003 348(26)2635-2645.
• Molinari NA. Medstat Marketscan data
  (unpublished)
• Rosenbaum S. State Immunization Coverage
  Standards Medicaid and Private Health Insurance
  NIC 2004 and www.gwhealthpolicy.org/immunization
• Cassidy W (et al). Can Emergency Department
  Visits Be Opportunities To Vaccinate Adults? A
  Pilot Study In an Urban Public Hospital. NIC
  2004 (abstract 5178)
• Shefer A et al. Improving immunization coverage
  rates an evidence-based review of the
  literature. Epidemiol Rev 21 (1)96-142, 1999.
• Stone EG, Morton SC, Hulscher ME, Maglione MA,
  Roth EA, Grimshaw JM et al. Interventions that
  increase use of adult immunization and cancer
  screening services a meta-analysis. Ann Intern
  Med 2002 136(9)641-651.
• Task Force on Community Preventive Services.
  Recommendations regarding interventions to
  improve vaccination coverage in children,
  adolescents, and adults. Am J Prev Med 18(1S),
  2000.
• Yarnall KS, Pollak KI, Ostbye T, Krause KM,
  Michener JL. Primary care is there enough time
  for prevention? Am J Public Health 2003
  93(4)635-641.