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Adult Vaccinations in Primary Care: Why They’re Important and How to Improve

Adult Vaccinations in Primary Care: Why They’re Important and How to Improve. Kristin L. Nichol, MD, MPH, MBA Professor of Medicine, University of Minnesota Medical School Associate Chief of Staff for Research, Minneapolis Veterans Affairs Medical Center Minneapolis, Minnesota.

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Adult Vaccinations in Primary Care: Why They’re Important and How to Improve

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  1. Adult Vaccinations in Primary Care: Why They’re Important and How to Improve Kristin L. Nichol, MD, MPH, MBA Professor of Medicine, University of Minnesota Medical School Associate Chief of Staff for Research, Minneapolis Veterans Affairs Medical Center Minneapolis, Minnesota

  2. Disclosures (cont.) • Dr. [insert local practice presenter’s name and disclosure] • This presentation will not include any non-FDA approved or investigational uses of products or medical devices [update if presentation has changed]

  3. Learning Objectives • After reviewing this material, you should be better able to • Identify which vaccines are indicated for adult patients • Summarize what the national vaccination goals are and current national performance • Describe barriers and strategies to enhancing adult vaccination rates • Propose 2 or more strategies that could enhance vaccination rates in your practice

  4. Impact of Vaccines During the 20th Century and Into the 21st Century *Underreporting estimated at a factor of 4.3 for hepatitis A and 2.8 for hepatitis B thus actual number of cases likely substantially higher than reported numbers of cases. CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book; 2011. Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm. Accessed June 15, 2011

  5. Burden of Selected Vaccine-Preventable Diseases (VPDs) CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book; 2011. Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm. Accessed June 15, 2011

  6. Vaccination Is the Best Way to Prevent and Control VPDs

  7. Recommended Adult Vaccines by Age Group Please see full reference for additional important footnote information. CDC. Adult immunization schedule. Available at: http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/adult-schedule.pdf. Accessed February 6, 2012.

  8. Recommended Adult Vaccines by Condition Please see full reference for additional important footnote information. CDC. Adult immunization schedule. Available at: http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/adult-schedule.pdf. Accessed February 6, 2012.

  9. Vaccination Rates Are Low CDC. 2009 Adult Vaccination Coverage, NHIS. Available at: http://www.cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm. Accessed June 13, 2011

  10. Baseline Vaccination Rates vsHealthy People 2020 Goals: Gaps Persist USDHHS. Healthy People 2020. Available at: http://www.healthypeople.gov/2020/default.aspx. Accessed June 13, 2011.

  11. Disparities Also Persist: NHIS 2009 CDC. 2009 Adult Vaccination Coverage, NHIS. Available at: http://www.cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm. Accessed June 13, 2011.

  12. So, Why Are Vaccination Rates So Low?

  13. Determinants of Vaccination Behavior Among Patients and Providers Are Well Described

  14. Critical Issues for Successful Vaccine Delivery • Patient • Provider • Vaccine supply and reimbursement • Policy

  15. Patient Issues for Vaccination • Awareness • Disease • Vaccine • Personal risk • Provider recommendation • Misconceptions/fears • About vaccine • About healthcare system • Access and ability to pay

  16. Medicare Beneficiaries’ Reasons for Not Getting Vaccinated • Lack of knowledge • Personal risk and need for vaccination • Misconceptions • About vaccines and VPDs • No recommendation from doctor CDC. MMWR Morb Mortal Wkly Rep. 1999;48(39):886-890. CDC. MMWR Morb Mortal Wkly Rep. 2004;53(43):1012-1015.

  17. Medicare Beneficiaries’ Reasons for Not Getting Vaccinated (cont.) Percentage aged 65 years who reported reasons for not receiving vaccinations1996 CDC. MMWR Morb Mortal Wkly Rep. 1999;48(39):886-890.

  18. Consumers’ Reasons for Not Getting Vaccinated • 2006 survey of 2002 people • Random-digit dialing, weighted responses to be representative of US population • Vaccines: influenza, pneumococcal, tetanus • Commonly cited reasons • I’m healthy, I don’t need it • My doctor hasn’t told me I need it • May have side effects • The cost of vaccinations was cited less often Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S28-35.

  19. Adults’ Main Reasons for Not Being Vaccinated Percentage of US adults who reported reasons for not receiving vaccinations2007 *Refers both to not knowing they should be vaccinated and not knowing enough about the vaccine. **Includes concern about getting sick from vaccine. Adapted from: Euler GL, CDC. Adult vaccination coverage, national immunization survey—adult, 2007. Available at: http://cdc.confex.com/cdc/nic2008/webprogram/Paper15390.html. Accessed June 13, 2011

  20. Consumer Misconceptions About Vaccines NFID. Saving lives: integrating vaccines for adults into routine care. Available at: http://www.nfid.org/pdf/publications/adultimmcta.pdf. Accessed June 13, 2011.

  21. Who Most Influences Adults’ Decisions to Get Immunized? NFID. 2009 National Adult Immunization Consumer Survey: Fact Sheet. Available at: http://www.adultvaccination.com/doc/Survey_Fact_Sheet.pdf. Accessed June 15, 2011. AMA. American Medical News. Physicians asked to persuade adults to get immunized. Available at: http://www.ama-assn.org/amednews/2009/08/03/prsc0803.htm. Accessed June 13, 2011.

  22. Inclination to Get Vaccinated Is Higher if Physician Recommends CDC. Adult immunization coverage information from CDC’s National Immunization Survey. Available at: http://www.nfid.org/pdf/pressconfs/adultimm08/cdcsurvey.pdf. Accessed June 15, 2011.

  23. Provider Recommendation Translates Into Higher Vaccination Rates (Even for Patients With Negative Attitudes) Vaccination Rates Among High-Risk* Patients With Negative Attitudes Vaccination Rate (%) *High-risk patients were those ages 65 and older or those having heart disease, lung disease, diabetes, or other serious illness. Nichol KL, et al. J Gen Intern Med. 1996;11(11):673-677.

  24. Disparities and Vaccination Barriers • Barriers • Health literacy • Mistrust of system • Language • Facilitators • Culturally appropriate education • Leveraging communities/trusted leaders/faith-based organizations • Translated materials Daniels NA, et al. J Natl Med Assoc. 2004;96(11):1455-1461. Chen JY, et al. J Community Health. 2007;32(1):5-20. Traeger M, et al. Am J Public Health. 2006;96(5):921-925. Logan JL. J Natl Med Assoc. 2009;101(2):161-166.

  25. What Can We Do to Increase Vaccination Rates?

  26. To Improve Vaccination Rates, Providers Should … • Know the facts • Recommend vaccinations to your patients • Get organized and use systems approaches • Ensure offering and administration of vaccines • Automatic processes that empower nurses are effective • Address convenience, efficiency, and durability • Evaluate and improve processes • Consider new paradigms • New venues • Extend vaccination season • Practice what we preach (get vaccinated!) Nichol KL. Cleve Clin J Med. 2006;73(11):1009-1015.

  27. Know the Facts:VPDs Are BAD, Vaccines (as Recommended) Are GOOD

  28. Types of Vaccines • Inactivated (“dead”) • Inactivated whole cell or subunit • TIV/flu shot • Hepatitis A and B • Acellular pertussis • HPV • Polysaccharide-based • Pneumococcal • Meningococcal • Toxoids • Td/Tdap • Live • MMR • Varicella/zoster • LAIV/flu vaccine nasal spray Avoid live virus vaccines for pregnant women and patients with severely compromised immune systems CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book; 2011. Available at: 12th:http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm. Accessed June 15, 2011..

  29. How Can Healthcare Providers Keep Up on Adult Vaccinations? • www.cdc.gov/vaccines • Adult Immunization Schedule (updated annually) • ACIP recommendations for each vaccine • Vaccine information statements (VIS) • Lots of other information on VPDs, vaccine safety, brochures, posters, and how to store and administer vaccines • www.immunize.org • The Immunization Action Coalition has lots of useful information for healthcare providers

  30. Know Them, Recommend Them

  31. Do Primary Care Providers Recommend Vaccines to Adults? % of Surveyed Primary Care Providers Who Recommended Influenza and Pneumococcal Vaccines 200 providers surveyed. Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S28-35.

  32. Beware of Assumptions! Reasons for Not Receiving Influenza or Pneumococcal Vaccinations Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S28-35.

  33. Get Organized to Get It Done

  34. Missed Opportunities • Missed opportunities are common • More than 50% of patients needing an influenza vaccine had at least one visit with a missed opportunity to vaccinate • Among persons needing pneumococcal vaccination, there were 10.7 missed opportunity visits over 3 years • Patient refusals uncommon Nowalk MP, et al. J Am Board FamPract. 2005;18(1):20-27.

  35. Practical Barriers to Vaccinating Adults in the Office Setting • Knowing what is recommended for whom • Having time to do it • Remembering to do it • Having adequate personnel to do it Nichol KL, Zimmerman R. Arch Intern Med. 2001;161(22):2702-2708. Szilagyi PG, et al. Prev Med. 2005;40(2):152-161.

  36. Interventions That Improve Vaccination Rates for Adults Stone EG, et al. Ann Intern Med. 2002;136(9):641-651

  37. Interventions That Improve Vaccination Coverage:Task Force on Community Preventive Services • Increase patient demand for vaccines • Patient reminder and recall systems • Clinic-based patient education • Manual outreach and tracking • Enhance access • Expanded access in healthcare settings • Reduced out-of-pocket costs to patients • Home visits • Address provider barriers • Provider reminders • Standing orders and policies • Provider assessment and feedback CPS Task Force. Universally recommended vaccinations: health care system-based interventions implemented in combination. Available at: http://www.thecommunityguide.org/vaccines/universally/healthsysteminterventions.html. Accessed June 13, 2011.

  38. Case Example: A Multifaceted Program Improved Success and Sustainability Nichol KL. Am J Med. 1998;105(5):385-392.

  39. Case Example: Impact of Multifaceted Program on Influenza Vaccination Rates Influenza Vaccination Rate (%) Baseline After Provider Education Multifaceted (Standing Orders) Multifaceted, Year 10 Nichol KL. Am J Med. 1998;105(5):385-392.

  40. Standing Orders Are Often Key Components of Success • Consistently among the most effective kinds of interventions to increase vaccination rates • Definition: policy/procedure/written order that allows qualified nurses, pharmacists, and other healthcare professionals (as allowed by state law) to assess and vaccinate patients who meet certain criteria • Eliminate need for direct physician involvement with each patient • Eliminate need for individual physician’s order for each patient • Appropriate settings: outpatient, inpatient, emergency department, long-term care, etc McKibben LJ, et al. MMWR Recomm Rep. 2000;49(RR-1):15-16.

  41. Standing Orders Are More Effective than Provider Education or Provider Reminders for Inpatients Influenza Vaccine Offering Rates by Type of Intervention Rates (%) ProviderEducation Provider Reminder Standing Orders Crouse BJ, et al. J FamPract. 1994;38(3):258-261.

  42. Opportunities for Improvement Abound Use of Effective Vaccination Strategies by US Physicians % Influenza Pneumonia Influenza Pneumonia Influenza Pneumonia Very Strongly Recommend Standing Orders Patient Reminders Nichol KL, Zimmerman R. Arch Intern Med. 2001;161(22):2702-2708.

  43. Vaccination Strategies Used by Subspecialists and Generalists Nichol KL, Zimmerman R. Arch Intern Med. 2001;161(22):2702-2708.

  44. Physician Practice and Interest in Selected Strategies for Influenza Vaccinations Szilagyi PG, et al. Prev Med. 2005;40(2):152-161.

  45. Tips on How to Move Forward • Establish baseline rate • Chart audit, numbers of vaccine doses, etc • Inventory current strategies used • Identify where • Current strategies could be improved • New strategies could be added • Involve the clinic team in planning and implementation • Pay attention to work flow, efficiency, etc

  46. Resources to Help • Immunization Action Coalition (www.immunize.org) • Adult Vaccination Guide (complete “how-to”) http://www.immunize.org/guide/ • Setting up for adult vaccination services • How to store and handle vaccines • Documenting • Sample standing orders • http://www.immunize.org/standing-orders/

  47. Vaccine Information Statements (VIS) from the CDC • Mandated by National Childhood Vaccine Injury Act (NCVIA) • Must be used for all vaccines covered by the act (regardless of age) • Includes most vaccines for adults • Strongly recommend for ALL vaccines • Obtain them from various Web sitesCDC, state health departments • Translations available in 30 different languages (www.IAC.org) CDC. Fact sheet for vaccine information statements. Available at: http://www.cdc.gov/vaccines/pubs/vis/vis-facts.htm. Accessed June 13, 2011.

  48. Healthcare Workers: Practice What We Preach!

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