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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.

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Presentation on theme: "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."— Presentation transcript:

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

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3 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]

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5 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

6 Impact of Vaccines During the 20th Century and Into the 21st Century Disease Reported Cases (Year) Reported Cases (2009) % Decrease in Reported Cases Diphtheria5796 (1950)0100% Tetanus486 (1950)1896% Pertussis120,718 (1950)16,85886% Measles319,124 (1950)71  99% Mumps152,209 (1968)199199% Rubella46,975 (1966)399% Hepatitis A*32,859 (1966)198794% Hepatitis B*26,611 (1985)340587% *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 ; Available at: Accessed June 15, 2011

7 Burden of Selected Vaccine- Preventable Diseases (VPDs) VPDBurden Influenza 200,000 excess hospitalizations annually (>40% in the elderly) ~24,000 excess deaths annually (~90% elderly) Invasive Pneumococcal Disease (IPD) ~50,000 cases of bacteremia each year Higher rates in elderly and persons with comorbidities Case fatality rates ~20% (up to 60% in the elderly) Hepatitis B 78,000 new infections annually (highest in young adults) 1 million with chronic hepatitis B virus infections Complications include cirrhosis and hepatocellular carcinoma (80% of cases) Human Papillomavirus (HPV) 6.2 million new infections each year 2 HPV strains cause 70% of cervical cancer Pertussis 10,454 cases reported in 2007 (3152 in adults) Most severe in infants *Source often older child or adult Shingles 500,000 to 1 million cases annually; lifetime risk ~32% Shingles and postherpetic neuralgia increase with age CDC. Epidemiology and Prevention of Vaccine-Preventable Diseases: The Pink Book ; Available at: Accessed June 15, 2011

8 Vaccination Is the Best Way to Prevent and Control VPDs

9 Recommended Adult Vaccines by Age Group Please see full reference for additional important footnote information. CDC. Adult immunization schedule. Available at: Accessed February 6, 2012.

10 Recommended Adult Vaccines by Condition Please see full reference for additional important footnote information. CDC. Adult immunization schedule. Available at: Accessed February 6, 2012.

11 Vaccination Rates Are Low VaccineVaccination Rate Influenza Age 19-49, high risk Age 50-64, total Age  65 Healthcare workers (19-64 years old) 33.4% 40.1% 65.6% 52.9% Pneumococcal Ages 19-64, high risk Age  % 60.6% Tetanus/pertussis since 2005 (19-64 years old)50.8% Shingles (60 years old and older)10.0% Hepatitis B (high risk, years old)41.8% HPV vaccine (women, years old)17.1% CDC Adult Vaccination Coverage, NHIS. Available at: Accessed June 13, 2011

12 Baseline Vaccination Rates vs Healthy People 2020 Goals: Gaps Persist Vaccine and Target GroupBaseline Rate (Year)Healthy People 2020 Goal Influenza vaccine Noninstitutionalized adults 18 to 64 years old Noninstitutionalized high-risk adults 18 to 64 years old Noninstitutionalized adults 65 years old and older Institutionalized adults 18 years old and older Healthcare personnel Pregnant women 25% (2008) 39% (2008) 67% (2008) 62% (2006) 45% (2008) 28% (2008) 80% 90% 80% Pneumococcal vaccine Adults 65 years old and older High-risk adults under 65 years old Institutionalized adults 60% (2008) 17% (2008) 66% (2006) 90% 60% 90% Zoster vaccine Adults 60 years old and older7% (2008)30% Hepatitis B vaccine Healthcare personnel64% (2008)90% USDHHS. Healthy People Available at: Accessed June 13, 2011.

13 Disparities Also Persist: NHIS 2009 Vaccine and Target Group Vaccination Rate, Non-Hispanic Whites Vaccination Rate, Non-Hispanic Blacks Vaccination Rate, Hispanics Influenza, 65 years old and older68.6%50.8%50.6% Pneumococcal, 65 years old and older64.9%44.8%40.1% CDC Adult Vaccination Coverage, NHIS. Available at: Accessed June 13, 2011.

14 So, Why Are Vaccination Rates So Low?

15 Determinants of Vaccination Behavior Among Patients and Providers Are Well Described

16 Critical Issues for Successful Vaccine Delivery Patient Provider Vaccine supply and reimbursement Policy

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

18 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): CDC. MMWR Morb Mortal Wkly Rep. 2004;53(43):

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

20 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.

21 Adults’ Main Reasons for Not Being Vaccinated *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, Available at: Accessed June 13, 2011 Percentage of US adults who reported reasons for not receiving vaccinations  2007

22 Consumer Misconceptions About Vaccines Category and Response % of Respondents in Agreement Vaccines and VPDs Had vaccines as a child—don’t need them again Vaccines not necessary for adults Not concerned about catching VPDs Not concerned about spreading illness to others VPDs are not serious or life threatening 40% 18% 34% 32% 25% Vaccine safety/efficacy Have heard vaccines are not safe Vaccines don’t work A vaccine made them sick 35% 14% 25% NFID. Saving lives: integrating vaccines for adults into routine care. Available at: Accessed June 13, 2011.

23 Who Most Influences Adults’ Decisions to Get Immunized? Ages Age 65 and OlderAll Adults Personal physician47%82%69% Family member33%6%19% Celebrity physician, public figure, other 11%4%7% None of the above7%6%4% No answer2%1% NFID National Adult Immunization Consumer Survey: Fact Sheet. Available at: Accessed June 15, AMA. American Medical News. Physicians asked to persuade adults to get immunized. Available at: Accessed June 13, 2011.

24 Inclination to Get Vaccinated Is Higher if Physician Recommends Physician Recommendation? Impact on Vaccination Yes87% are very or somewhat likely to get vaccinated No 55% would not get vaccine unless recommended by doctor CDC. Adult immunization coverage information from CDC’s National Immunization Survey. Available at: Accessed June 15, 2011.

25 Provider Recommendation Translates Into Higher Vaccination Rates (Even for Patients With Negative Attitudes) Vaccination Rates Among High-Risk* Patients With Negative Attitudes *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): Vaccination Rate (%)

26 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): Chen JY, et al. J Community Health. 2007;32(1):5-20. Traeger M, et al. Am J Public Health. 2006;96(5): Logan JL. J Natl Med Assoc. 2009;101(2):

27 What Can We Do to Increase Vaccination Rates?

28 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):

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

30 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 ; Available at: 12th:http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm. Accessed June 15,

31 How Can Healthcare Providers Keep Up on Adult Vaccinations? 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 The Immunization Action Coalition has lots of useful information for healthcare providers

32 Know Them, Recommend Them

33 Do Primary Care Providers Recommend Vaccines to Adults? Patient GroupInfluenzaPneumococcal Elderly37%65% Lung disease45%68% Diabetes31%44% Heart disease20%29% 200 providers surveyed. Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S % of Surveyed Primary Care Providers Who Recommended Influenza and Pneumococcal Vaccines

34 Beware of Assumptions! Cited by HCPsCited by Consumers Fear of needles>65%<20% Cost>60%  15% Reasons for Not Receiving Influenza or Pneumococcal Vaccinations Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S28-35.

35 Get Organized to Get It Done

36 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 Fam Pract. 2005;18(1):20-27.

37 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): Szilagyi PG, et al. Prev Med. 2005;40(2):

38 Interventions That Improve Vaccination Rates for Adults ComponentOdds Ratio (OR) Organizational change16.0 Provider reminder3.8 Patient financial incentive3.4 Provider education3.2 Patient reminder2.5 Patient education1.3 Provider financial incentive1.3 Feedback1.2 Stone EG, et al. Ann Intern Med. 2002;136(9):

39 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: Accessed June 13, 2011.

40 Case Example: A Multifaceted Program Improved Success and Sustainability StrategyTactics Increase demandAnnual reminder to patients Enhance accessWalk-in clinics Address provider barriersInstitutional policy Standing orders Standardized forms Efficient clinic flow Ongoing measurement and evaluation Nichol KL. Am J Med. 1998;105(5):

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

42 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.

43 Standing Orders Are More Effective than Provider Education or Provider Reminders for Inpatients Crouse BJ, et al. J Fam Pract. 1994;38(3): Provider EducationProvider ReminderStanding Orders Influenza Vaccine Offering Rates by Type of Intervention Rates (%)

44 Opportunities for Improvement Abound Nichol KL, Zimmerman R. Arch Intern Med. 2001;161(22): Influenza Use of Effective Vaccination Strategies by US Physicians PneumoniaInfluenzaPneumoniaInfluenzaPneumonia Very Strongly RecommendStanding OrdersPatient Reminders %

45 Vaccination Strategies Used by Subspecialists and Generalists StrategyInfluenzaPneumococcal Very strongly recommend for elderly patients75-86%64-81% Increase demand Patient reminders Clinic-based patient education 14-24% 25-52% 9-14% 18-40% Enhance access Special clinics10-27%5-10% Provider-oriented Provider reminders Standing orders Assessment/feedback on vaccination rates for elderly 26-39% 20-29% 20-38% 24-37% 13-19% 18-33% Nichol KL, Zimmerman R. Arch Intern Med. 2001;161(22):

46 Physician Practice and Interest in Selected Strategies for Influenza Vaccinations Doing AlreadyWould Try Patient reminders23%53% Walk-in clinic67%19% Policy to assess status at each visit48%31% Standing orders33%36% Clearer vaccine guidelines33%51% Registry7%56% Szilagyi PG, et al. Prev Med. 2005;40(2):

47 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

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

49 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: Accessed June 13, 2011.

50 Healthcare Workers: Practice What We Preach!

51 Immunizations and Healthcare Workers (HCWs) “First do no harm” Recommended vaccinations/immunity Influenza MMR Hepatitis B Varicella Tdap Special situations Meningococcal for microbiologists with potential for exposure Other vaccinations based on personal risk characteristics Immunization Action Coalition. Healthcare personnel vaccination recommendations. Available at: Accessed June 15, 2011.

52 Summary VPDs are an important cause of morbidity and mortality in adults We have safe and effective vaccines that are underused For patients, misconceptions about VPDs and vaccines and lack of provider recommendation are important factors in not being immunized For providers, missing opportunities and failing to recommend vaccination are important shortcomings

53 Summary (cont.) Interventions to increase vaccination rates should include efforts to enhance demand, improve access, and address provider and systems issues In addition to vaccinating their patients, providers should also be vaccinated Lots of Internet resources are available to help

54 Internet Resources CDC’s National Immunization Program Immunization Action Coalition National Foundation for Infectious Diseases CMS State health departments


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