Howard Backer and Sheila Mackell

Transcription

1 Potential Cost-Savings and Quality Improvement in Travel Advice for Children and Families from a Centralized Travel Medicine Clinic in a Large Group-Model Health Maintenance Organization Howard Backer and Sheila Mackell Background: Cost, as well as accuracy and quality of medical care, is an important factor from the perspective of the health care payer. We evaluated the potential pharmacy cost savings, appropriateness of recommendations, and patient satisfaction associated with a proposed centralized travel medicine service in a large group-model health maintenance organization (HMO). Methods: From computerized pharmacy records, we identified 101 children 18 years of age or younger from six different facilities of Kaiser Permanente in northern California who obtained malaria prophylaxis, typhoid vaccine, or yellow fever vaccine for international travel from their primary care practitioner. We obtained records of all vaccinations and prescriptions provided to each patient and interviewed their parents concerning medical services they received in preparation for travel. We compared what vaccinations and prescriptions were actually given to expert recommendations, and compared total pharmacy costs for actual versus recommended care. Results: Travel advice obtained from primary care practitioners in this system was often inefficient and varied from expert recommendations. Primary care practitioners frequently overestimated risk, leading to unnecessary prescribing, especially of mefloquine and typhoid vaccine. This created potential cost-savings of US $12 per patient (17% of total pharmacy costs per patient). We were unable to quantify additional savings that could result from improved efficiency of providing care. Conclusions: A travel medicine clinic staffed by practitioners who provide expert and current advice may provide savings in pharmaceutical costs as well as improvements in quality of care compared to primary care practitioners without expertise in travel medicine. Pretravel advice, immunizations, and malaria prophylaxis have the potential to prevent serious health problems from infections and injuries among international travelers. 1 Although advice is available from a variety of sources, 2 travelers are encouraged to consult with a nurse or physician who can provide appropriate immunizations and prescriptions. However, it has been demonstrated that many general practitioners are unable to provide optimal and accurate travel preparation, so there is an Howard Backer, MD, MPH: Emergency Department, Kaiser Permanente Medical Center, Hayward (Currently Immunization Branch, California Department of Health Services); Sheila Mackell, MD: Pediatrics, Kaiser Permanente Medical Center, Oakland, California. This work was supported by a grant from the Innovations Program, The Permanente Medical Group, Kaiser Permanente Northern California. The authors had no financial or other conflicts of interest to disclose. Reprint requests: Howard Backer, MD, 2151 Berkeley Way Room 712, Berkeley, CA J Travel Med 2001; 8: advantage to seeking advice from an experienced or dedicated travel clinic. 3 Many patients do not seek any advice, perhaps related to their limited knowledge of the risks or to their perceived level of risk, but another factor is likely to be cost. Depending on health coverage, vaccinations and medications can add significantly to the cost of an already expensive trip. Travel medicine experts may provide more accurate advice and immunizations, but there is little data to show whether this results in higher or lower costs of providing that care. Cost, as well as accuracy and quality, is also an important factor from the perspective of the health care payer. Comprehensive, prepaid health care services, such as health maintenance organizations (HMOs) and other health plans, look carefully at the cost of travel services and vary widely in their coverage of pretravel consultation and vaccinations. Travel preparation is often viewed as nonessential care for an elite group of patients that can afford to pay for the care out-of-pocket.the visit to the health professional may be covered by insurance, but the travel vaccinations may not be covered. Since few travelers acquire serious, vaccine-preventable infections, cost-effectiveness studies do not offer convincing arguments to provide many immunizations when basic preventive measures are available. 4,5 247

2 248 Journal of Travel Medicine, Volume 8, Number 5 We evaluated the potential pharmacy cost savings, as well as appropriateness of recommendation and patient satisfaction associated with a proposed centralized travel medicine service in a large group-model HMO. We focused on traveling families with children because we felt that care was fragmented between pediatric and adult medical practitioners, and there has been little or no research into the practice of pediatricians providing travel advice. Northern California is the home base of Kaiser Permanente (KP), the first health maintenance organization, and the first to promote prepaid, capitated health care. Currently, Kaiser Permanente Northern California (KPNC) provides health care to nearly three million members through 15 medical centers and 23 outpatient clinics. Each northern California facility organizes travel medicine services independently, using a mix of physician visits, consultation with telephone advice nurses, and injection clinic nurses. Moreover, pediatric and adult services are provided separately, which may lead to conflicting advice. Although practitioners may consult standardized travel advice from public and proprietary resources, these sources over-generalize recommendations since they cannot account for the range of itineraries and activities. We hypothesized that this results in inappropriate variations in practice that may also create higher costs due to overuse of immunizations. Methods Our target population consisted of children 18 years of age or younger from different families who traveled out of the country in 1999 to a high risk area and received prophylaxis for malaria, or immunization for typhoid,or yellow fever.all patients were seen at one of six different Kaiser Permanente facilities on the east side of San Francisco Bay, representing a broad spectrum of professional and working class persons and a very mixed ethnic group. To identify study subjects, we searched the KPNC clinical information system, which contains extensive patient demographic and medical information for children 18 years of age or younger,who received one of the following during the time period January 1 September 1, 1999: (1) a prescription for mefloquine or chloroquine (date and details of prescription indicated use for prophylaxis), (2) prescription for oral typhoid vaccine or immunization with injectable typhoid vaccine without malaria prophylaxis, or (3) immunization for yellow fever, but no prescription for malaria. These index markers were selected to provide a range of geographic destinations in areas with some risk of tropical disease for which it is important to receive pretravel advice and preparation. We also identified all other prescriptions likely related to travel and travel immunizations given during a period of 30 days before,or after,the above index travel intervention. Medications included ciprofloxacin, doxycycline, trimethoprim-sulfamethoxazole, diphenoxylate, and loperamide. Vaccines included typhoid, yellow fever, polio booster, hepatitis A, rabies (HDCV), Japanese encephalitis, and meningococcal vaccine. The computerized clinical record was searched individually for each subject to identify any prescriptions or immunizations missed by the main data pull or that were given in prior years. The study group consisted of subjects randomly selected from each of the three groups above to achieve an approximate composition of 60% from group 1, 30% from group 2,and 10% from group 3.Children from the same family as the randomly selected index case and patients treated by one of the authors were excluded. A parent of each study subject was contacted by telephone, and after informed consent was obtained, was asked to answer a short questionnaire asking the location and duration of travel, which family members traveled, how they obtained travel advice and preparation, and the parents opinion of these services. One author (SM) determined the necessary and appropriate vaccinations and malaria prophylaxis regimen for each study subject. This was based on standard expert resources (including the Centers for Disease Control and Prevention), current accepted practice within the United States, and current medical literature. These were then compared to the actual immunizations and prescriptions given, to determine accuracy of advice, and to provide the basis for generating actual and expert-recommended pharmacy costs for each study patient. Appropriateness of care was determined by agreement with expert opinion on prescription for malaria prophylaxis and immunizations (excluding polio, since it is a routine childhood immunization). Prescriptions for presumptive treatment of travelers diarrhea were also not considered when determining appropriateness of pretravel care (see discussion). Costs for pharmacy items were provided by the KPNC regional pharmacy and calculated from purchase order cost calculated at dispense time. To extrapolate our data and provide estimates of cost savings for our study area, and for all of the KPNC region, we used several measures to determine the number of travelers. The pharmacy database supplied the number of antimalarial prescriptions and specific travel immunizations region-wide and by facility. Data from the author s pediatric travel medicine clinic at the largest medical center in the study area (Oakland) provided an esti-

3 Backer and Mackell, Cost-Savings and Quality Improvement from Centralized Travel Advice 249 Table 1 Age (years) Age Distribution of Study Subjects Number/Percent N = 101. Table 2 Region Destination of Travel Number/Percent Africa 6 Southeast Asia 2 India/China 25 Pacific/Philippines 29 Mexico/Central America 19 South America 10 Middle East 3 Other (Eastern Europe, Japan, Taiwan) 6 mate of the proportion of antimalarial prescriptions and immunizations to the total number of pretravel visits, allowing a crude estimate of the total number of travel visits and percentage requiring specific interventions. All data was entered into a computer. Data analysis was done using Excel (Microsoft Office 97), SAS (SAS Institute, Cary, NC), or Stata (version 5.0, College Station, TX). Analytic statistics included the Pearson s correlation, chi-square and Fisher s exact tests, and Kappa and McNemar s chi-square for correlated proportions. This study was approved by the KPNC Investigational Review Board. Results Demographics of Study Group The initial pharmacy data query found the following among children 18 years old or younger in our six study facilities from January 1 through August 31, 1999: 550 mefloquine prescriptions, 134 chloroquine prescriptions, 1,127 typhoid vaccines administered (oral or injectable), and 87 yellow fever vaccinations. After applying inclusion and exclusion criteria, 810 index patients qualified to participate in the study. The final study group consisted of 101 pediatric patients ranging from 6 months to 18 years of age. The mean age was 10.7 years and the median was 11 years (Table 1). Fifty-nine percent were identified by antimalarial prescription, 33% by typhoid immunization, and 8% by yellow fever immunization without malaria prophylaxis. After all computer records were manually searched again for travel-related immunization, 24% of Table 3 N = 101. children in the study group had received typhoid without malaria prophylaxis and 7% had received yellow fever without malaria prophylaxis. Destination of travel is shown in Table 2. Seventy percent of these trips were to visit family.thus,the most popular destinations reflect countries of origin for this population. The mean length of travel was 4.3 weeks and the median 3 weeks (range 1 28 weeks). Overall, 70% (75% of those visiting family) visited urban destinations where there is lower risk of problems like malaria. Thirty percent of the children and 34 (42%) parents traveling with their children had traveled to the same destination within the past 3 years. Eighteen percent of the children traveled without their parents. Provision of Travel Services Each family contained an average of 3 people who were covered under a KP health plan and went on the trip. However, only a mean of 2.4 persons per family obtained pretravel advice and immunizations (Table 3). Thirty-one (36%) parents who traveled with their children did not seek travel advice for themselves. Members received travel preparation from a number of sources (Table 4). Nearly two-thirds had an appointment with a physician, but still required contact with an advice nurse and injection nurse. More than one-third also sought information from an outside source, usually the Internet, books, or an organization that sponsored the trip. Forty-three percent required separate visits for the child Number of Family Members Who Traveled and Number Who Sought Travel Advice from KP Number of Persons per Family Mean How many immediate family members who were covered under your Kaiser health plan traveled? 19* How many family members received travel advice or immunizations through Kaiser? *Number of families, not individuals. Number of individuals from each family.

4 250 Journal of Travel Medicine, Volume 8, Number 5 Table 4 Sources of Travel Information, Prescriptions, and Immunization Orders Appointment with doctor at Kaiser 73 Telephone advice nurse without seeing a doctor 67 Injection nurse without seeing doctor 91 Travel clinic or medical doctor outside Kaiser 4 Outside resources (Internet, books, organization, etc.) 36 % * Table 5 Percent Who Did Not Recall Receiving Prevention Information on Specific Travel Risks Malaria 23 Insect bite prevention 37 Travelers diarrhea 41 Motor vehicle safety 71 Safe drinking water 32 % *Total equals more than 100% because multiple choices allowed. and adults. On average, each family required 2 phone calls and 1.3 visits to KP to obtain travel advice, generating a total of 130 visits and 196 calls for this group of 101 families, not counting visits only for injections or to pick up prescriptions. The number of family members correlated with the number of visits and calls required to obtain travel preparation (p =.0001) (Figure). Consistency and Completeness of Pretravel Recommendations Fifteen percent of parents who were traveling with their children received different travel recommendations from an adult medical provider than the children had received from the pediatrician. These differences were not consistently explained. Many parents did not recall receiving important travel advice or information (Table 5). Only 50% of those receiving malaria prophylaxis remember receiving information about the importance of prophylaxis, 19% denied receiving information on this topic. This may have contributed to the 37% of both adults and children who were prescribed malaria prophylaxis but did not complete it as prescribed. More than 40% denied receiving any information on travelers diarrhea prevention and treatment. Thirty percent of the children did experience diarrhea during their trip, but 90% of their families stated that they had not been given instructions or medication to treat the diarrhea. Figure Visits and calls required to obtain travel preparation. Pearson s correlation coefficient 0.42, p = Accuracy and Cost The accuracy and cost of immunizations and prophylaxis actually given were compared to the expert recommendations. Care was deemed inappropriate in the majority (59%) of cases. We did not judge any instances where hepatitis A was given as inappropriate, since it is becoming a routine childhood vaccination in California. However, there were 4 patients who should have received it but did not. The most variation occurred in the provision of malaria prophylaxis, yellow fever vaccination, and typhoid vaccination (Table 6). There were 12 patients who received mefloquine and 6 who received chloroquine that did not need any prophylaxis. Examples of this type of error were patients who received mefloquine but only traveled to Manila in the Philippines. There was only 1 patient who was given nothing who should have been given chloroquine. Yellow fever vaccine was also overprescribed. In 6 cases it was not necessary, and in only 1 patient was it omitted when it was indicated. Of 101 patients, typhoid vaccination was given 22 times when it was not necessary and omitted in 9 patients for whom it was indicated. We used several statistical measures to evaluate the accuracy of travel advice provided compared to our expert opinion (Table 7). However, we are more interested in the level of disagreement. The simplest and most direct comparison is to evaluate sensitivity and specificity assuming that our expert opinion is the truth and we are comparing it to a test which is the primary practitioners practice. The Kappa statistic measures the Table 6 Variation between Actual Practice and Opinion of Travel Medicine Expert Should Not Have Been Given Should Have Been Given Yellow Fever Vaccine Not given to patient 88 1 Given to patient 6 6 Typhoid (oral and inactivated combined) Not given to patient 14 9 Given to patient 22 56

5 Backer and Mackell, Cost-Savings and Quality Improvement from Centralized Travel Advice 251 Table 7 Measures of Agreement between Actual and Recommended Pharmaceuticals (N = 101) Sensitivity % (CI) Specificity (CI) Kappa McNemar Chi-Square Pr > z Malaria 96 ( ) 62.5 (47 76) Typhoid Vaccine 86 (75 93) 41.6 ( ) Yellow Fever 85.7 ( ) 93.6 ( ) CI = Confidence Interval. level of agreement compared to agreement by chance alone for two different observers. McNemar s chi-square evaluates the expected versus observed values for paired observations. The average actual pharmaceutical cost was US $72 per child, whereas the estimated cost for the expert recommendation was $60 per child. The overall savings on pharmaceutical costs for our 101 study patients would be $1,226, approximately 17%. Fifty-six percent of the savings came from excessive prescribing of malaria chemoprophylaxis. An additional 25% can be attributed to excessive use of typhoid vaccine. Other vaccines contribute smaller amounts to the savings. Extrapolated to our study area, we estimate the total pediatric pharmaceutical cost for pretravel immunizations to be $183,528, and for the entire northern California region, $567,288. If we were able to achieve comparable savings in this larger pediatric travel population, it would amount to savings of $30,588 for our study area and $96,439 for the entire region. Discussion This study suggests that a travel medicine clinic staffed by practitioners who provide expert and current advice may provide savings in pharmaceutical costs compared to primary care practitioners without expertise in travel medicine. Most of our savings came from the overuse of malaria prophylaxis and vaccines, probably as a result of practitioners consulting general guidelines without knowledge of more specific geographic or temporal guidelines, or without eliciting enough itinerary detail to determine that no prophylaxis or vaccine was needed. Prescribing errors in our study population were mostly those of excess rather than omission. This is reflected in the high sensitivity and low specificity when comparing actual prescribing to optimal recommendations. In addition to cost, excessive prescribing increases the risk of adverse drug reactions. Mefloquine use is already controversial for many patients; although this risk is acceptable when the benefit is preventing lifethreatening Plasmodium falciparum malaria, it is unacceptable when this risk does not exist. Typhoid vaccination provides an excellent example of the need to apply knowledge of geographic medicine and individual traveler s risk to the decision of using the vaccine. 1,5,6 Most travelers are at very low risk, yet many practitioners give this vaccine indiscriminately to any travelers going outside of the most developed countries. It also may be overused in many travel clinics because patients frequently want all vaccines that might be given. For judging appropriateness of care, our criteria was travel of any length to an area of high risk (e.g., India, or Africa), rural or adventure travel to any typhoid endemic areas,or travel of at least 3 weeks to urban areas of countries with lower risk. Keystone et al. demonstrated overuse of antimalarial prophylaxis and both unnecessary and omitted immunizations using travel scenarios to test travel medicine recommendations among health practitioners. 3 Townend also found highly variable immunization and antimalarial practices for trekkers to India and Nepal, including many vaccinations that were not needed. 7 Optimal prescribing in travel medicine, as in all areas of medicine, impacts cost and quality. However, neither Keystone et al. nor Townend calculated cost implications for specific travelers. 3,7 Conflicting pressures to provide more care under restricted budgets burden capitated health care systems. As a result, they rationally demand that cost efficacy of interventions, including travel immunizations and the organization of health care delivery are evaluated. 4,8 In one of the few attempts to determine the cost-benefit ratio of several travel interventions, Behrens and Roberts found that malaria prophylaxis had a very favorable costbenefit ratio; however, the cost effectiveness of hepatitis A and typhoid was debatable. 4 Kozarsky and Dawood debated the issue of providing maximal immunizations for international travelers. 5,9 The consensus was the need to add risk to each traveler into the equation with benefit and cost, which requires the considerable knowledge and expertise of a travel medicine practitioner. 10 Although immunizations and prescriptions are important to prepare patients for international travel, information for the prevention of illness and injury is equally important. 1,6 Injury is the most common cause of mortality among travelers, and behavioral practices affect the risk of a number of infectious illnesses from travelers diarrhea to arthropod-borne and sexually transmitted infections. Our data suggest that families did not receive adequate information on safety and preventive measures

6 252 Journal of Travel Medicine, Volume 8, Number 5 such as travel with car seats, the importance of malaria prophylaxis, how to manage travelers diarrhea and prevent dehydration (despite the higher risk in children), and the importance and methods to prevent insect bites. This may have resulted in the high percentage of travelers who stated that they did not take their malaria prophylaxis as prescribed. The predominance of patients who were traveling to visit families creates an added challenge for travel medicine practitioners. These parents often travel to small villages in remote areas with small children. Our study included parents who did seek advice for their children, yet many did not seek advice for themselves. This may reflect a belief that no special care is required since they are returning to a former homeland, and many had traveled to the same destination within the past 3 years. Nearly as many children (30%) had traveled to the same destination in the past 3 years, but the parents still brought them for travel advice. If malaria prophylaxis is needed, prior preparation or recent travel without illness does not protect the parent. The 130 visits and 196 calls, plus visits to the pharmacy and injection nurses that were required to prepare these 101 families for their travel, suggested an inefficient means of providing healthy preventive travel services. Given the fragmented provision of travel services within our system, it is possible that a centralized service that provided care for the parents and children at the same visit would also save office visits and add to the cost effectiveness. However, since most of the consultations for travel patients involve undocumented staff time, and there is no designation in our computerized visit documentation for a pediatric travel consultation, we could only make very crude estimates of potential savings. Although we had believed that physicians enjoyed these travel consultations, our discussions with them suggested that they were a difficult intrusion and that these pediatricians were not comfortable providing the advice. Our interviews also indicated that patients would be more satisfied receiving care in one place, and it would improve patient satisfaction by assuring that discordant advice is not given for parents and children. Costs in health care are highly variable and dependent on measurement methodology. We considered only direct medical costs, not indirect costs to the patient. However, a well-organized travel service should offer better patient service and convenience, thereby reducing indirect costs, and more efficient use of professional staff can favorably affect direct medical costs. Study Limitations There are several limitations to our study and its conclusions. The primary issue is whether this data can be generalized to other patient populations and health care systems given the specific demographics of our region and the design of our health care system. The inconsistencies of travel advice from primary care practitioners without large travel practices are well documented in a variety of settings. 3,6,7 Our cost calculations would be sensitive to many factors that were not considered in this study. Pharmacy prices may vary considerably; KP generally receives very favorable pricing because of the purchasing volume. Higher prices could increase the potential cost savings if the errors were mostly over-prescribing. Currently all our vaccinations, including travel vaccinations, are provided at no cost to health plan members. However, this is not true in most other systems, including some of the other KP regions.if patients must pay full price or copay for these vaccines, it may discourage some from requesting a vaccine like typhoid that has questionable benefit for most travelers. Since our patients currently do not pay anything for their vaccines, including travel vaccines, our actual costs might be inflated if patients insisted on receiving vaccines of questionable benefit. As more vaccines are routinely provided to segments of the population, such as meningococcal vaccine and hepatitis A, the cost of travel preparation may decrease. Our small sample did not include many patients who needed the less commonly used and expensive vaccines such as rabies preexposure prophylaxis and Japanese encephalitis. Finally, capturing the parents at the time of their children s visit, who would not have sought travel advice for themselves, could also add to the costs. We did not calculate the cost of prophylactic treatment for travelers diarrhea (TD). Practitioners of pediatric travel medicine differ in their philosophy of presumptive treatment of TD. Many provide instructions and medication only for symptomatic care. Apparently, presumptive antibiotic treatment of TD is given much more frequently to adults than children. In fact, only 2 of our pediatric study patients were given a prescription for trimethoprim-sulfamethoxazole or ciprofloxacin. The cost of trimethoprim-sulfamethoxazole is only about $1.50, so it would not negate our savings. If ciprofloxacin is approved for this use in children, it could add significantly to the cost of travel preparation and decrease the cost savings, assuming that pediatricians do not prescribe it to traveling children but that the travel clinic would do so. The same could occur if azithromycin became the standard medication for presumptive treatment of TD in children. Although the frequency and type of errors in prescribing for antimalarials or typhoid are valid, our overall percentage of inappropriate recommendations and total potential cost savings extrapolated to the larger region are not valid, because this was not a random sampling of travel consultations. We selected patients randomly only

7 Backer and Mackell, Cost-Savings and Quality Improvement from Centralized Travel Advice 253 after identifying groups of patients who received medications and immunizations, suggesting travel to high-risk areas. Furthermore, we searched for some patients presumed to have inappropriate advice, i.e., yellow fever vaccine but no malaria prophylaxis. This was done specifically to identify patients who require the most pretravel resources and the most careful advice. This study was subject to recall bias. Although the interviews were all done within the same year as the preparation and travel, our study subjects may have had inaccurate recall of the number of calls, visits, and specific advice. Self-reported utilization is less susceptible to recall bias than what specific information was provided. The post-travel itinerary may have been more precise than the pretravel itinerary given to the primary care physician, leading to extra vaccination which was not needed in retrospect. Although the immunizations given were based on an accurate pharmacy database and not subject to recall bias, some immunizations may have been omitted because of prior immunization history that was not in this database. Despite these limitations, these data suggest that organized travel services may produce cost-savings in pharmacy products alone, an important argument to initiate these services within large health care systems. Reorganizing systems to provide optimal quality, patient access, and service, are other potential advantages. Much of what is done in travel medicine has a very high costbenefit ratio, so the provision of vaccines and medications should be based on current travel and tropical medicine epidemiology. Acknowledgments The authors would like to gratefully acknowledge the assistance and contributions of Kathleen Benedict who helped with database design and data analysis, and Diane Galligan who performed the interviews. References 1. Steffen R, Lobel H. Epidemiologic basis for the practice of travel medicine. J Wilderness Med 1994; 5: Leggat P. Sources of health advice given to travelers. J Travel Med 2000; 7: Keystone J, Dismukes R, Sawyer L, Kozarsky P. Inadequacies in health recommendations provided for international travelers by North American travel health advisors. J Travel Med 1994; 1: Behrens RH, Roberts RJ. Is travel prophylaxis worthwhile? Economic appraisal of prophylactic measures against malaria, hepatitis A, and typhoid in travellers. BMJ 1994; 309: Kozarsky P. Maximum immunization for travel: Con. J Travel Med 1995; 2: Ryan E, Kain K. Health advice and immunizations for travelers. N Engl J Med 2000; 342: Townend M. Sources and appropriateness of medical advice for trekkers. J Travel Med 1998; 5: Behrens RA, Roberts RJ. Travel prophylaxis (letter). BMJ 1995; 310: Dawood R. Maximum immunization for travel: Pro. J Travel Med 1995; 2: Wiedermann G. Maximum immunization for travel: consensus. J Travel Med 1995; 2: Traveling on the Amazon River with the boat named Juliana. This boat was used for the film Fitzgerald. Submitted by Danielle Gyurech, MD and Julian Schilling, MD.