Transcript Protecting Our Health The Importance of Vaccinations

Overcoming Barriers and
Other “How To’s”
Priti Patel, MD, MPH
Division of Healthcare Quality Promotion
National Center for Preparedness, Detection, and Control
of Infectious Diseases
The findings and conclusions in this presentation are those of the author(s) and
do not necessarily represent the views of the Centers for Disease Control and Prevention
Outline
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Healthy People goals
Barriers to Implementation
Evidence-based Strategies
Resources
Healthy People 2010
Immunization Goals for
Renal patients and providers
Immunization
Patients
Staff
Pneumococcal
pneumonia
90%
n/a
Hepatitis B
90%
98%
Influenza
90%
* (all)
* No HP objective yet but recommended by CDC, ACIP
and HICPAC for all healthcare workers
Patient Influenza Vaccination
Rates by Network,
STIC 2005-06
6
11
15
All
# of Centers
(≥ 20 pts)
360
241
176
777
Mean (SD)*
73.5%
78.7%
76.9%
75.9%
(19.5%)
(15.2%)
(15.8%)
(17.6%)
78.5%
81.8%
80.9%
80.0%
64.5% to
71.4% to
69.1% to
68.2% to
87.0%
89.9%
86.5%
87.9%
Median
IQ range
(25th-75th
percentile)
Influenza vaccination rates across Networks 6, 11, and 15 (2005-06)
100%
19.8% at or above 90%
90%
Vaccination rate
80%
70%
60%
40%
20%
0%
15.1% below 60%
Facilities ordered by rate (n=777)
Why aren’t more patients
immunized?
Barriers
Patients
Providers
Institutions
Systems
Barriers & Strategies:
High Risk Adults
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High-Risk Adult
Population
ESRD
Patients
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Persons targeted for vaccination
because they are at increased
risk for complications from
influenza
Criteria
– Persons aged 65 or older*
– Residents of nursing homes
and chronic care facilities*
– Persons with chronic lung,
heart, or renal disease,
diabetes,
immunosuppression, or
neurologic disorders that can
compromise respiratory
function*
– Pregnant women
Barriers to Adult Immunization:
Patient & Provider
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Not knowing immunizations are
needed
Misconceptions about vaccines
Lack of recommendations from
health care providers
Barriers to Adult Immunization:
Systems
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Access to healthcare
Opportunities for prevention
Cost / Reimbursement
ESRD
Population
Other High-Risk
Adult Populations
Vaccination rates among
Adults ≥ 65 years by
Race / ethnicity, 2000-2001
70
% Immunized
60
50
White
Black
Hispanic
40
30
20
10
0
Influenza
Pneumovax
CDC. MMWR 2003; 52(40):958-962
Strategies
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Task Force on Community
Preventive Services reviewed
evidence for various interventions
Recommended interventions
– Enhance access to vaccines
– Provider or systems-based
– Increase community demand for
vaccines
STIC Interventions
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Standing orders
Provider reminder systems
Provider assessment and feedback
Patient reminders
Patient education
Others
Standing Orders
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Definition: written order stipulating that all
persons meeting certain criteria should be
vaccinated, thus eliminating the need for
individual physician’s orders for each
patient
Advantages:
– The most consistently effective method for
increasing adult vaccination rates
– Easy to implement
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Disadvantages:
– Only reaches patients already contacting
the health care system
Standing Orders:
Implementation
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Decide what criteria will be used
to indicate patient eligibility for
vaccination
Write standing order
Meet with staff to discuss
implementation of the standing
order
Monitor vaccination rates
(suggested)
Resources needed:
– Standing order
Sample Standing
Order Policies
Available at the
Immunization Action
Coalition Website
www.immunize.org/standingorders/
Provider reminder systems
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Informs the provider that individual patient is
due for vaccine
 Examples:
– Notation, prompt, or sticker
in patient chart
– Standardized checklists
– Computerized database or
registry
Chart Reminders: Tips
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Can be as simple as a colorful
sticker on the chart
Should be prominently placed in
the chart
Reminders that require some
acknowledgment, even a simple
checkmark by the physician, are
more effective
Chart Reminders:
Implementation
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Design or identify a chart reminder to
use
Make copies to be inserted into all
appropriate patient records
Assign a staff person to place the
reminders in a prominent place in the
chart
Resources Needed:
– Staff time
– Chart reminders
Computerized Record
Reminder
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Computer print-out of reminders that
appear on a patient’s record
Use software to determine dates that
certain immunizations are due or past due
and then print reminder messages, usually
overnight, for patients with visits
scheduled for the next day
Advantages:
– Inexpensive once computerized system is
in place
– Efficient
Disadvantages:
– Only reaches patients with office visits
Computer Record
Reminder: Implementation
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Design or identify a computerized
reminder system to use
Train professional staff in the use of
the computerized reminders.
Resources Needed:
– Computer program linked to medical
records or billing data to generate
reminders
– Computerized medical records
Provider assessment and
feedback
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Evaluate performance of
providers in delivering
vaccinations
Give this information to
providers
Provider assessment and
feedback
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Advantages:
– Competition increases motivation and provider
compliance with vaccination recommendations
– Immediate feedback on each provider’s
performance
– Easy to implement
– Each provider can use his/her own approach to
improve vaccination rate
– Evaluation is built into this approach
Disadvantages:
– Time to train staff and implement strategy
– Requires continual tracking of vaccination rates
Provider assessment and
feedback: Implementation
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Determine number of eligible patients (denominator)
May need to generate lists of patient names
Create or adopt target-based poster on which to
track number of patients vaccinated
Hold meetings with staff to explain the graphic
denominator-based tracking system
Each week, providers should record all influenza
vaccinations given to at-risk patients, tabulate the
cumulative weekly total, and calculate the
percentage of the target population vaccinated
Resources Needed:
– Staff time
– Poster to track vaccinations given
Patient Reminders
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Notification to patients that vaccinations are
due
Gives patient opportunity to come in for
vaccination
Can be delivered by telephone, letters, or
postcards
Patient Reminders
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Advantages:
– Phone contact ensures that the message is
understood
– Reaches patients who may otherwise not
have scheduled visits
– Easy to implement, requiring minimal staff
time
Disadvantages:
– Relies on patient to make & keep
appointment
– Not useful in practices with a population that
changes residences frequently
– May need bilingual reminders
– Generating the list of patients who should
receive reminders may be difficult in some
practices
Patient Reminders:
Implementation
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Generate a list of patients to be reminded
(manually or via computerized billing or
medical records)
Review list to remove patients who have
died, transferred to another provider, left
the area, or received vaccinations
Develop reminder
Send reminders or place calls (6 calls a
day, 5 days a week for eight weeks = 240
patients contacted)
Schedule appointments
Resources Needed:
– Staff time
– Telephone script or postcards
Patient Education
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Provide patients information on
vaccinations
Can include posters, brochures,
videos, newsletters, classes or
lectures
Should improve understanding and
generate demand for vaccines
Patient Education
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Advantages:
– Inexpensive and easy to implement,
requiring minimal staff time
– Patients can ask questions and receive
feedback
– Does not require generating a patient list
Disadvantages:
– Only reaches patients already in contact
with health care providers
– Using only written materials not useful in
practices with low literacy levels
– May need bilingual information sheets
Patient Education:
Implementation
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Create or identify appropriate patient
information sheet* or use the Vaccine
Information Statement (VIS)
Assign a staff person to distribute
information sheet or VIS
Follow-up to answer questions
Resources Needed:
– Staff time
– Handouts
* See the STIC Toolkit for Educational Materials
VIS sheet: http://www.cdc.gov/vaccines/pubs/vis/downloads/vis-flu.pdf
Other Interventions to
Consider
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Immunization Education Day / Week
Immunization Counseling
Staff Vaccination Initiative
Monitoring
Patient Immunization Wallet Cards
Check-boxes incorporated into order
sheets
Address patient
and provider
misconceptions
Myth-busting
http://www.cdc.gov/flu/professionals/flugallery/2007-08/pdf/f_factmyth_8x11.pdf
Myth-busting
http://www.cdc.gov/flu/professionals/flugallery/2007-08/pdf/f_factmyth_8x11.pdf
Myth-busting
http://www.cdc.gov/flu/professionals/flugallery/2007-08/pdf/f_factmyth_8x11.pdf
Protect patients,
Protect healthcare personnel,
Promote quality healthcare
Prevention Is
Primary!
The information in this presentation has not been formally
disseminated by the Centers for Disease Control and
Prevention and should not be construed to represent any
agency determination or policy