1. Offering Free Vaccination Eliminates Disparities in Adult Immunization But Low Cost Vaccination Does Not Free vs. Cheap Daniel B. Fishbein, William B. Cassidy, Dale Bell Marioneaux, Monica Pradhan, Mark Messonnier, Doug Schwalm, Noelle-Angelique Molinari, Carla Winston
Good morning. Today I’m going to present some background information about a public health issue that you are all familiar with – dreadfully low levels of vaccination in people between the ages of 18-64, and propose a radical solution – take most of the process out of the hands of physicians and put it into the hands of trained paramedical personnel. The presentation is entitled “Offering Free Vaccination Eliminates Disparities in Adult Immunization But Low Cost Vaccination Does Not - but to cut to the chase its about free versus cheap – not only for the patient but also for the provider
Free vs. Cheap: The effect of cost on disparities in adult immunization

2. Collaborators CDC LSU NVPO 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
We would like to acknowledge our co-investigators and collaborators

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
Series of studies. The first two will be briefly presented as background, and then I will present in depth

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 time pressure, 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.”
Even if the provider chooses to place more emphasis on prevention, will he/she emphasize what our CIO thinks is important?

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
Reduced time pressure and cognitive complexity

9. Assessment-Reminder (A/R) Tool
Assess patients vaccination needs
Self- or assisted-administration
Reminds patient and provider about indicated vaccinations
Adapted from Do I Need Any Vaccinations Today (IAC)
Translates ACIP recommendations for eight vaccines into lists of questions
Written at a 4th grade reading level
Available in English and Spanish
The self-assessment-physician reminder tool was adapted from Do I Need Any Vaccinations Today (Immunization Action Coalition, Minneapolis, MN).13 The tool translates ACIP recommendations for eight vaccines (influenza; pneumococcal polysaccharide; measles, mumps, and rubella; meningococcal; tetanus-diphtheria, varicella; hepatitis A; hepatitis B[n1]) into lists of questions derived from ACIP criteria and written at a 4th grade reading level and available in English and Spanish.12 The lists combine demographics, health conditions, age and health condition of household members, occupational exposures, recreational activities and travel plans, sexual preferences, behaviors all based on ACIP recommendations.1 A “yes” response to any item in a list for a vaccine means that vaccine is indicated. This listing strategy avoids the need to reveal specific sensitive information. A final question asks the respondent he or she has already received the correct number of doses of the vaccine in the proper time period. [n2]Thus, all medical personnel can use this form without compromising privacy concerns.
The self-assessment-physician reminder tool (assessment-self-assessment tool) translates ACIP recommendations for eight vaccines (influenza; pneumococcal polysaccharide; measles, mumps, and rubella; hepatitis A; hepatitis B; varicella, meningococcal) into a series of Yes/No questions derived from ACIP criteria as well as previous vaccination history. The self-assessment tool was written at a 4th grade reading level and was available in English and Spanish.9 For each vaccine, the tool listed a series of items that were individually sufficient to classify whether the vaccine was recommended. Depending on the vaccine, the list included demographics, health conditions, occupational exposures, recreational activities and travel plans, sexual preferences, behaviors, as well as the age and health condition of household members, all based on ACIP recommendations for the individual vaccine.1 Since each list contained non-sensitive information (e.g. travel plans) alongside sensitive information (e.g. drug use), sensitive information and specific risk factors are not disclosed. For example, for hepatitis A, a single list included both travel to an endemic area and street drug use. For this reason, a variety of different types of medical and paramedical personnel can use the form to assist in determining vaccination needs without knowing sensitive information about the patient’s health conditions and behavioral risk factors.
Assesses vaccination need, history, & VPD risk factors
Reminds providers to discuss vaccines that might be needed

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

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
Little or no provider involvement in process
Are patients willing to let non-MDs “do it all”
Do EDs work better because you can separate the contributions, or because each aspect is strong on its own and there is a separation of powers?
That is, in a doctor’s office, the doctor is the captain of the ship, but in an ED, the institution (represented by the RN and intake clerk) is one power; the MD is another power.

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
ED patients have ASSETS. These include:
Lack of insurance (so low vaccination coverage, which makes ED sites more attractive to programs trying to hit pockets of need and more attractive to economists who want to gain efficiency)
Lack of time outside the ED because of work/family/hourly wage
Lack of preventive and general health care (so EDs can be an efficient site of vaccination)
Healthy patients (the majority? Well, at any rate, they’re the ones most likely to get vaccinated) have more captive time in a system that favors true emergencies. During this captive time, education can take place.

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. Moving To Emergency Rooms Is Every Visit a Missed Opportunity to Vaccinate?
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
Need to describe the clinic (control group).
Tested the usual health care mechanism

18. Assessment-Reminder Tool: Urban Emergency Room vs. Clinic
Y-axis label is a percent

19. Assessment-Reminder Tool: Urban Emergency Room vs. Clinic
Well-done!
Conclusion at this point of your talk is that….

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. Separate the contribution of the institution: Financial disincentives Willingness to Pay For Vaccinations
Setting
Sample and design
Data
Outcome
Urban emergency department, mix of low and middle income, many minority, December 2003-January 2004
600 consecutive patients 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
Was 200 the minimum sample size allowable for each intervention/control group? Since you find no difference in demographics among groups for many variables, this is important.

22. Demographic Characteristics, By Randomization Status
Age, mean (SE)
37.3 (0.94)
38.9 (0.91)
35.8 (0.89)*
18-49
77% (156)
74% (147)
83% (164)
Gender, female
58% (118)
55% (108)
61% (120)
Race, black
79% (159)
77% (153)
81% (160)
Income<$1000/m
41% (75)
43% (79)
47% (84)
Insurance, private
51% (96)
50% (94)
43% (77)
Medicaid
26% (51)
24% (48)
30% (58)
First line is confusing because the parentheses refer to SE rather than n. You might want to say SE, rather than putting 0.94 in parentheses.
Overall, busy slide. Might be better if you reduced the font a notch and put more separation between lines.
p<0.05 compared to $5 group

23. Selected Characteristics, by Race
Black (n=469)
Non-black* (n=124) P
Age, 18-49
82% (383)
65% (80)
<0.0001
Gender, female
60% (280)
51% (63) NS
Income<$1000/mo
49% (206)
22% (24)
Insurance, private
43% (190)
70% (80)
Medicaid
28% (127)
17% (48)
0.02
* 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
Persuasive. Good. Statistical significance?

28. Vaccine Receipt, By Cost
2010 Target

29. Vaccine Receipt, By Cost
2010 Target

30. Vaccine Receipt, By Race

31. Vaccine Receipt, By Race
Would delete horizontal lines

32. Vaccine Receipt, By Race
Chi square

33. Accepted Influenza Vaccination, Logistic Regression
Variable OR
95% CI P
Cost, free
Ref $5
0.19
<0.001
$10
0.14
Not significant: age, gender, race, Medicaid, income, private insurance,

34. Accepted Pneumococcal Vaccination, Logistic Regression
Variable OR
95% CI P
Cost, free
Ref $5
0.08
0.001
$10
0.03
<0.001
Race, non-black
black
0.19
0.015
Controlling for age, gender, income, private insurance, Medicaid

35. Accepted Hepatitis B Vaccination, Logistic Regression
Variable OR
95% CI P
Cost, free
Ref $5
0.13
0.006
$10
0.002
Controlling for: age, gender, race, income, Medicaid, private insurance
Same thinking here. Having CI eliminates and overrides the benefit of P values (a less robust statistical test)
Also, I prefer only 3 levels of p: <0.05, <0.01, and < Taught that way by a CDC statistician who said that if you have less than 1/1000 chance, it’s a rare chance indeed. The interim values such as don’t really help you understand the likelihood of something occurring by chance alone, compared with

36. Cost Analysis Total cost Screening, administration, vaccine
Influenza: $17.72
Pneumococcal: $28.23
Hepatitis B: $28.45
You probably don’t have time to include this slide. Would use it as a back-up slide only.
Use tab to line up (right-justify) all costs in the right column. Too confusing.
Also, what’s the typically billed fee? Allowable fee?

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
You probably don’t have time to include this slide. Would use it as a back-up slide only.
Use tab to line up (right-justify) all costs in the right column. Too confusing.
Also, what’s the typically billed fee? Allowable fee?

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
What’s the relative contribution of the A/R form in the ED? If unclear, should be studied.

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 Freedom Amartya 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