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

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]

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

Impact of Vaccines During the 20th Century and Into the 21st Century Disease Diphtheria Tetanus Pertussis Measles Mumps Rubella Hepatitis A* Hepatitis B* Reported Cases (Year) 5796 (1950) 486 (1950) 120,718 (1950) 319,124 (1950) 152,209 (1968) 46,975 (1966) 32,859 (1966) 26,611 (1985) Reported Cases (2009) 0 18 16,858 71 1991 3 1987 3405 % Decrease in Reported Cases 100% 96% 86%

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99% 99% 99% 94% 87% *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

Burden of Selected Vaccine Preventable Diseases (VPDs)

VPD Influenza Invasive Pneumococcal Disease (IPD) Hepatitis B Burden 200,000 excess hospitalizations annually (>40% in the elderly) ~24,000 excess deaths annually (~90% elderly) ~50,000 cases of bacteremia each year

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Higher rates in elderly and persons with comorbidities

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Case fatality rates ~20% (up to 60% in the elderly) 78,000 new infections annually (highest in young adults)

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1 million with chronic hepatitis B virus infections

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Complications include cirrhosis and hepatocellular carcinoma (80% of cases) Pertussis Shingles 10,454 cases reported in 2007 (3152 in adults) Most severe in infants *Source often older child or adult 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; 2011. Available at: http://www.cdc.gov/vaccines/pubs/pinkbook/default.htm. Accessed June 15, 2011

Vaccination Is the Best Way to Prevent and Control VPDs

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.

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.

Vaccination Rates Are Low

Vaccine Influenza Age 19-49, high risk Age 50-64, total Age

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65 Healthcare workers (19-64 years old) Pneumococcal Ages 19-64, high risk Age

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65 Tetanus/pertussis since 2005 (19-64 years old) Shingles (60 years old and older) Hepatitis B (high risk, 19-49 years old) HPV vaccine (women, 19-26 years old) Vaccination Rate 33.4% 40.1% 65.6% 52.9% 17.5% 60.6% 50.8% 10.0% 41.8% 17.1% CDC. 2009 Adult Vaccination Coverage, NHIS. Available at: http://www.cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm. Accessed June 13, 2011

Baseline Vaccination Rates vs Healthy People 2020 Goals: Gaps Persist Vaccine and Target Group 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 Pneumococcal vaccine Adults 65 years old and older High-risk adults under 65 years old Institutionalized adults Zoster vaccine Adults 60 years old and older Hepatitis B vaccine Healthcare personnel Baseline Rate (Year) Healthy People 2020 Goal 25% (2008) 39% (2008) 67% (2008) 62% (2006) 45% (2008) 28% (2008) 60% (2008) 17% (2008) 66% (2006) 7% (2008) 64% (2008) 80% 90% 90% 90% 90% 80% 90% 60% 90% 30% 90% USDHHS. Healthy People 2020. Available at: http://www.healthypeople.gov/2020/default.aspx. Accessed June 13, 2011.

Disparities Also Persist: NHIS 2009

Vaccine and Target Group Influenza, 65 years old and older Pneumococcal, 65 years old and older Vaccination Rate, Non-Hispanic Whites 68.6% 64.9% Vaccination Rate, Non-Hispanic Blacks 50.8% 44.8% Vaccination Rate, Hispanics 50.6% 40.1% CDC. 2009 Adult Vaccination Coverage, NHIS. Available at: http://www.cdc.gov/vaccines/stats-surv/nhis/2009-nhis.htm. Accessed June 13, 2011.

So, Why Are Vaccination Rates So Low?

Determinants of Vaccination Behavior Among Patients and Providers Are Well Described

Critical Issues for Successful Vaccine Delivery

 Patient  Provider  Vaccine supply and reimbursement  Policy

Patient Issues for Vaccination

 Awareness   Disease Vaccine  Personal risk  Provider recommendation  Misconceptions/fears   About vaccine About healthcare system  Access and ability to pay

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.

Medicare Beneficiaries’ Reasons for Not Getting Vaccinated

(cont.) Didn't know No doctor recommendation Didn't remember Shot causes diseases Side effects Doesn't work Pneumococcal (n=6926) Influenza (n=4503) 0 10 20 30 40 50 60 Percentage aged

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65 years who reported reasons for not receiving vaccinations

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1996 70 CDC. MMWR Morb Mortal Wkly Rep. 1999;48(39):886-890.

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.

Adults’ Main Reasons for Not Being Vaccinated

Not needed Didn't know* No doctor recommendation Side effects** Cost 0 Tetanus Tdap Zoster HPV 10 20 30 40 50 Percentage of US adults who reported reasons for not receiving vaccinations

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2007 60 *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

Consumer Misconceptions About Vaccines

% of Respondents in Agreement Category and Response 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 Vaccine safety/efficacy Have heard vaccines are not safe Vaccines don’t work A vaccine made them sick 40% 18% 34% 32% 25% 35% 14% 25% NFID. Saving lives: integrating vaccines for adults into routine care. Available at: http://www.nfid.org/pdf/publications/adultimmcta.pdf. Accessed June 13, 2011.

Who Most Influences Adults’ Decisions to Get Immunized?

Personal physician Ages 18-26 47% Age 65 and Older 82% All Adults 69% 33% 6% 19% Family member Celebrity physician, public figure, other None of the above No answer 11% 7% 2% 4% 6% 1% 7% 4% 1% 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.

Inclination to Get Vaccinated Is Higher if Physician Recommends Physician Recommendation? Impact on Vaccination Yes 87% 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: http://www.nfid.org/pdf/pressconfs/adultimm08/cdcsurvey.pdf. Accessed June 15, 2011.

Provider Recommendation Translates Into Higher Vaccination Rates (Even for Patients With Negative Attitudes) Vaccination Rates Among High-Risk* Patients With Negative Attitudes 100 No recommendation Recommendation 82% 85.1% 80 60 40 20 0 27% 15.8% Influenza PPV

*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.

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.

What Can We Do to Increase Vaccination Rates?

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.

Know the Facts: VPDs Are Are

GOOD BAD

, Vaccines (as Recommended)

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..

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

Know Them, Recommend Them

Do Primary Care Providers Recommend Vaccines to Adults?

% of Surveyed Primary Care Providers Who Recommended Influenza and Pneumococcal Vaccines Patient Group Elderly Lung disease Diabetes Heart disease Influenza 37% 45% 31% 20% Pneumococcal 65% 68% 44% 29% 200 providers surveyed.

Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S28-35.

Beware of Assumptions!

Reasons for Not Receiving Influenza or Pneumococcal Vaccinations Fear of needles Cost Cited by HCPs >65% >60% Cited by Consumers <20%

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15% Johnson DR, et al. Am J Med. 2008;121(7 Suppl 2):S28-35.

Get Organized to Get It Done

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.

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.

Interventions That Improve Vaccination Rates for Adults

Component Organizational change Provider reminder Patient financial incentive Provider education Patient reminder Patient education Provider financial incentive Feedback Odds Ratio (OR) 16.0

3.8

3.4

3.2

2.5

1.3

1.3

1.2

Stone EG, et al. Ann Intern Med. 2002;136(9):641-651

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.

Case Example: A Multifaceted Program Improved Success and Sustainability Strategy Increase demand Enhance access Address provider barriers Tactics Annual reminder to patients Walk-in clinics Institutional policy Standing orders Standardized forms Efficient clinic flow Ongoing measurement and evaluation Nichol KL. Am J Med. 1998;105(5):385-392.

Case Example: Impact of Multifaceted Program on Influenza Vaccination Rates 100 80 60 40 20 0 Baseline After Provider Education Multifaceted (Standing Orders) Multifaceted, Year 10 Nichol KL. Am J Med. 1998;105(5):385-392.

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.

Standing Orders Are More Effective than Provider Education or Provider Reminders for Inpatients Influenza Vaccine Offering Rates by Type of Intervention 100 80 60 40 20 0 Provider Education Provider Reminder Standing Orders Crouse BJ, et al. J Fam Pract. 1994;38(3):258-261.

Opportunities for Improvement Abound

Use of Effective Vaccination Strategies by US Physicians 100 80 Generalists Subspecialists 60 40 20 0 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.

Vaccination Strategies Used by Subspecialists and Generalists

Strategy Very strongly recommend for elderly patients Increase demand Patient reminders Clinic-based patient education Enhance access Special clinics Provider-oriented Provider reminders Standing orders Assessment/feedback on vaccination rates for elderly Influenza 75-86% 14-24% 25-52% 10-27% 26-39% 20-29% 20-38% Pneumococcal 64-81% 9-14% 18-40% 5-10% 24-37% 13-19% 18-33% Nichol KL, Zimmerman R. Arch Intern Med. 2001;161(22):2702-2708.

Physician Practice and Interest in Selected Strategies for Influenza Vaccinations Patient reminders Walk-in clinic Policy to assess status at each visit Standing orders Clearer vaccine guidelines Registry Doing Already 23% 67% 48% 33% 33% 7% Would Try 53% 19% 31% 36% 51% 56% Szilagyi PG, et al. Prev Med. 2005;40(2):152-161.

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

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/

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.

Healthcare Workers: Practice What We Preach!

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: http://www.immunize.org/catg.d/p2017.pdf. Accessed June 15, 2011.

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

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

Internet Resources

 CDC’s National Immunization Program  www.cdc.gov/vaccines  Immunization Action Coalition  www.immunize.org

 National Foundation for Infectious Diseases  www.nfid.org

 CMS  www.cms.gov/AdultImmunizations/  State health departments