1. Increasing (Late Season) Influenza Vaccinations- Baton Rouge William Cassidy, MD Louisiana State University Health Sciences Center

2. Acknowledgements LSU –Dale Marrioneaux –Aubrey Lipham –Sal Baghian –Baton Rouge General Staff –Our Lady of the Lake Staff CDC –Dan Fishbein –Susan Manning –Edith Gary

3. Outline Question Reasons for low immunization rates Phases of “Baton Rouge” Effort –Isolating variables –Results Conclusions

4. Question Are reasons for decreased late season flu immunization different from reasons for decreased early season flu immunization.

5. Outline Question Reasons for low immunization rates Phases of “Baton Rouge” Effort –Isolating variables –Results Conclusions

6. Patient Reasons to be Un-Vaccinated Inadequate Knowledge, Attitudes & Practices (KAP) –knowing, caring or wanting Expense –Direct cost of vaccine & MD visit –Indirect cost of missing work

7. Providers Reasons to not Vaccinate Inadequate Provider KAP –Non traditional providers (ex. ER Docs) –Extension of vaccination season Direct and Indirect “Costs” –Cost of vaccine and vaccination –Counseling can be very time consuming

8. Outline Question Reasons for low immunization rates Phases of “Baton Rouge” Effort –Isolating variables –Results Conclusions

9. Changes KAPDirect Cost Indirect Cost Patient$0 Provider$0 Phase 1 of 4, Assessment/Reminder forms for 6 vaccines in 3 Primary Care Settings Conclusions: Providers did not give recommended vaccines, unable to assess effect of increasing patient KAP Results: No significant increase in immunizations in the intervention group.

10. Changes KAPDirect Cost Indirect Cost Patient A/R FORM $0 Provider Standing Orders, Provider not involved Phase 2 of 4 Para-professionals approached ED patients, Immediate vs. Later Vaccination

11. Phase 2: Indirect Cost to Patients Results - Immediate vaccination with greater acceptance rate. Conclusions – Eliminating patient’s indirect costs significantly increases vaccination coverage Note: Provider role eliminated

12. Changes KAPDirect Cost Indirect Cost Patient A/R FORM $0, 5, 10 $0 Provider + Provider signed standard order Phase 3 of 4, Para-professionals Using A/R Forms, Patients Randomized to $0, $5, $10 Co-pay

13. Phase 3: Varied Patient Direct Costs Results –Incremental increases in a patient’s direct cost decreased vaccination acceptance Conclusions – –ED immunization facilitated by para- professionals feasible Note: Providers minimally involved

14. Changes KAPDirect Cost Indirect Cost Patient A/R FORM $0 Provider$0 Phase 4a of 4, City Wide Effort: Para-professionals Using A/R Forms, Providers signing standard orders Results: Anomalous year Larger ED with better cost benefit ratio

15. Phase 4b, Baton Rouge Efforts November 2005 – March 2006 Larger hospital assessed 24/7 Smaller hospital assessed 10 A to 10 P Physicians signed standard orders Nurses vaccinated

16. Changes KAPDirect Cost Indirect Cost Patient A/R FORM $0 Provider$0 Phase 4b of 4, Para-professional - A/R Forms, Providers signing standard orders 2 Busiest Emergency Departments

17. Racial Disparities AAAA Vax Rate Non AA Non AA Vax Rate P Value Screened1729556 ACIP risk1332427 UTD37528.2%19645.9% Vaccinated 32624.5%8119.0% Total coverage52.6%64.9%

18. Influenza Vaccination, Patients in ACIP Risk Groups by Race, Hospital A ED, Dec. 5-Feb. 16 * *

20. Question Are reasons for decreased late season flu immunization different from reasons for decreased early season flu immunization.

21. Late Season Immunization No significant decrease in late and early season acceptance of flu immunization

22. Patient Reasons to be Un-Vaccinated Inadequate Knowledge, Attitudes & Practices (KAP) Direct and Indirect “Costs” Providers Reasons to not Vaccinate Inadequate Provider KAP Direct and Indirect “Costs”

23. Overall Conclusions Para-professionals in EDs can increase patient’s KAP towards flu vaccination Eliminating patient’s direct & indirect cost increases immunization rates ED immunization decreases disparities Providers: Role is problematic

24. Conclusions of Phase 4b Late flu season immunization is feasible and accepted by patients. Patient issues with late flu immunization are the same as early season issues Provider issues may be important

25. Outline Question Reasons for low immunization rates Phases of “Baton Rouge” Effort –Isolating variables –Results Conclusions