Collaborators

1. 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

2. 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 D’Autramont Collaborators NVPO

3. 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

4. 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

5. 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

6. Racial and Ethnic Disparities • “The conditions in which many clinical encounters take place, characterized by high timepressure, 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

7. 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.”

8. 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

9. Assessment-Reminder (A/R) Tool • Assess patients vaccination needs • Self- or assisted-administration • Reminds patient and provider about indicated vaccinations

10. 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 Separating the Contribution of the Provider I: Family Practice Clinics

11. 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

12. 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

13. 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

14. 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

15. Trend in Emergency Department Visit Rates United States, 1992-2001 NOTE: Trend is significant (p<0.05).

16. Emergency Department Visits By Age And Race United States, 2001

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

18. Assessment-Reminder Tool: Urban Emergency Room vs. Clinic

19. Assessment-Reminder Tool: Urban Emergency Room vs. Clinic

20. 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

21. 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 Separate the contribution of the institution: Financial disincentivesWillingness to Pay For Vaccinations

22. Demographic Characteristics, By Randomization Status p<0.05 compared to $5 group

23. Selected Characteristics, by Race * Most white but included 7 others; 7 missing

24. Statistically significant Associations with Acceptance of Vaccine in the ED Univariate analysis

25. Vaccine Receipt, By Cost 2010 Target

26. Vaccine Receipt, By Cost 2010 Target

27. Vaccine Receipt, By Cost 2010 Target

28. Vaccine Receipt, By Cost 2010 Target

29. Vaccine Receipt, By Cost 2010 Target

30. Vaccine Receipt, By Race

31. Vaccine Receipt, By Race

32. Vaccine Receipt, By Race P=0.003 Chi square

33. Accepted Influenza Vaccination, Logistic Regression Not significant: age, gender, race, Medicaid, income, private insurance,

34. Accepted Pneumococcal Vaccination, Logistic Regression Controlling for age, gender, income, private insurance, Medicaid

35. Accepted Hepatitis B Vaccination, Logistic Regression Controlling for: age, gender, race, income, Medicaid, private insurance

36. Cost Analysis • Total cost • Screening, administration, vaccine • Influenza: $17.72 • Pneumococcal: $28.23 • Hepatitis B: $28.45

37. 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

38. 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

39. Conclusion 1: By ED Physician • “Everybody wants something for free”

40. 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

41. 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

42. 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