Standing Orders and Adult Immunizations: A Foundation for Improving Coverage Rates

Transcription

1 Standing Orders and Adult Immunizations: A Foundation for Improving Coverage Rates Litjen (L.J) Tan, MS, PhD Chief Strategy Officer, Immunization Action Coalition Co-Chair, United States Adult and Influenza Immunization Summit May 25th, 2018 Disclaimer The opinions expressed in this presentation are solely those of the presenter and do not necessarily represent the official positions of the Immunization Action Coalition, or the United States Adult and Influenza Immunization Summit

2 Outline Update on Adult Immunizations Burden of disease Coverage Rates Why Standing Orders What are standing orders and who recommends them? Why aren t standing orders used? Do standing orders improve vaccination rates? How standing orders benefit medical practices Essential components of standing orders Challenges Burden of Adult Vaccine-preventable Disease Among U.S. Adults Invasive pneumococcal disease (IPD) 1 29,500 total cases and 3,350 total deaths in % of IPD and nearly all IPD deaths among adults Influenza 2 3,000 to 49,000 total related deaths per year ~90% among adults 65 years and older Pertussis 3 20,762 total reported cases ,650 among adults 20 years of age & older Hepatitis B 4 2,791 acute cases reported ,100 estimated new infections in 2014 Zoster 5 about 1 million cases of zoster annually U.S. 1. CDC Active Bacterial Core Surveillance Report, Emerging Infections Program Network, Streptococcus pneumoniae, CDC. Estimates of deaths associated with seasonal influenza United States, MMWR. 2010;59(33): CDC Final Pertussis Surveillance Report. nloads/pertuss-surv-report pdf. 4. CDC. Viral Hepatitis Surveillance United States. 14surveillance/pdfs/2014hepsurveill ancerpt.pdf CDC. Prevention of Herpes Zoster. MMWR (RR-5): 1-30.

3 Incidence of invasive pneumococcal disease among adults aged years with select underlying conditions, United States, 2009 Kyaw. JID 2005;192: Impact of Vaccination Influenza Acute respiratory illness or influenza-like illness increases acute MI risk 2x; 5x is those with history of MI Influenza vaccination effectiveness: Meta-analyses % (95%CI 9,44) against acute MI in persons with existing CVD 36% (95%CI 14,53) against major cardiac events with existing CVD Vaccine effectiveness 29% in acute MI prevention On par or better than accepted preventive measures [as] statins (36%), anti-hypertensives (15 18%), and smoking cessation (26%) Influenza vaccination recommended as secondary prevention by American College of Cardiology and American Heart Association 1. Barnes M, et al. Acute myocardial infarction and influenza: a meta-analysis of case control studies. Heart 2015;101: Udell JA, et al. Association between influenza vaccination and cardiovascular outcomes in high-risk patients: a meta-analysis. JAMA 2013;310:

4 Cost Burden of 4 Adult Vaccine- Preventable Diseases in Persons Age 65 Years and Older, United States, 2013 Vaccine-Preventable Disease Estimated # of CASES Estimated COSTS (Medical & Indirect) (in millions) Influenza 4,019,759 8,312.8 Pneumococcal 440,187 3,787.1 Zoster 555,989 3,017.4 Pertussis 207, $15,329.8 Additional $11.2 billion in costs if ages years included McLaughlin, JM, Tan L., et al. J Primary Prevent (2015) 36: Adult Immunizations result in health and productivity gains Professionally active person who has influenza-like illness will take, on average, 2 to 5 days of sick leave Multiplied by the number of working individuals infected in different economic sectors - $$$$ Not to mention considerable proportion of their earnings lost In Norway, the mean number of working days lost for seasonal influenza annually was estimated to be 793,000, resulting in an estimated productivity loss of US$231 million Two-thirds of working adults (aged 50-65) who had shingle or PHN stopped working and about 75% reported decreased effectiveness at work (i.e., presenteeism) during almost 2 days Quilici et al J Mark Access Health Policy;3: /jmahp.v

5 Adult Immunizations result in health and productivity gains Patients with chronic diseases, such as diabetes or chronic heart disease, are at higher risk of adult VPDs In US, diabetes was associated with 45% and 18% adjusted risks for HZ and PHN People with underlying conditions accounted for the greatest share of total costs avoided due to influenza vaccination Vaccination of the 65 and older contributes to a more active and healthier aging population Higher risk of severe outcomes from infections Vaccine Preventable Disability and its associated costs Quilici et al J Mark Access Health Policy;3: /jmahp.v Example: Cervical cancer hits women during their most economically productive years Bärnighausen et al Clin Microbiol Infect 2012; 18 (Suppl. 5): 70 76

6 Yet, We are Failing to Vaccinate our Adult Population! Adult Immunization Coverage Rates, National Health Interview Surveys, Tetanus past 10y, age 65 Tetanus past 10y, age Pneumococcal, age 65 Pneumococcal, age at high risk Healthy People 2020 target Zoster, age 60 Percent Williams, W.W. et al. MMWR Surveillance Summary 2017;66(11):1 28

7 Influenza Vaccination Coverage Among U.S. Adults, Past Four Seasons 1 Group (%) (%) (%) (%) Persons > 18 yrs * 43.3 ± 0.6* Persons yrs, all ± 0.8 Persons yrs, high risk ± 1.8 Persons yrs * 45.4 ± 1.0* Persons 65 yrs * 65.3 ± 1.0* * Statistically significant declines/increases from the previous season So here s our problem Patients aren t protected from vaccine preventable diseases Adult immunization rates are appallingly low Missed opportunities abound Patients aren t receiving ACIP recommended vaccinations during office visits Clinicians time-pressed with competing priorities Acute and chronic medical issues first Lack of time for vaccinations and other preventive health measures

8 Standing Orders A Solution The goal of using standing orders is to increase vaccination coverage by: Reducing missed opportunities in your health care setting Routinizing vaccination by making it a program rather than relying on an individual clinician s order for each dose of vaccine Empowering nurses (or other legally qualified individuals) to manage your vaccination program Improving efficient use of clinician time by freeing clinicians from active roles in immunization Public Health Rep. 2014;129(2): Yonas, et al. J Healthcare Quality.2012;34: What Are Standing Orders?

9 Standing Orders What Are They? Written protocols, approved by a physician or other authorized practitioner, that authorize nurses, pharmacists or other health care personnel (where allowed by state law) to: Assess a patient s need for vaccination Administer the vaccine without a clinician s direct involvement with the individual patient at the time of the interaction Who Recommends Use of Standing Orders? The Community Preventive Services Task Force recommends standing orders to increase vaccination coverage among adults and children on the basis of strong evidence of effectiveness.

10 Who Recommends Use of Standing Orders? The Advisory Committee on Immunization Practices (ACIP) recommends standing orders for influenza and pneumococcal vaccinations and several other adult vaccines. CDC. MMWR. 2000;49(RR-1):1-26. Who Recommends Use of Standing Orders? Centers for Medicare and Medicaid Services (CMS) Certification/SurveyCertificationGenInfo/downloads/SCLetter03-02.pdf

11 Why Aren t Standing Orders Used? Lack of standing orders implementation may be due to: Weak or no organizational support Gaps in education, training, perceived benefits Small size of the clinical support staff relative to providers Logistical and workload concerns Concerns about legal ramifications Zimmerman et al. Am J Prev Med 2011; 40(2): Yonas, et al. J Healthcare Quality.2012;34: Vaccine Injury Compensation Program Established by National Childhood Vaccine Injury Act (1986) Provides no-fault compensation for specified injuries that are temporally related to specified vaccinations Program has greatly reduced the risk of litigation for both providers and vaccine manufacturers Covers most routinely recommended vaccines, including those administered to adults, with a couple of exceptions: Pneumococcal Polysaccharide Zoster

12 Do Standing Orders Improve Vaccination Rates? Are Standing Orders Effective? Based on a 2015 review of 35 studies ( ) that examined standing orders either alone or combined with other activities*, the Community Preventive Services Task Force found: Used alone, standing orders increased adult vaccination coverage by a median of 16 percentage points (range: 9% to 29%) Used in combination with other interventions,* standing orders increased adult vaccination coverage by a median of 27 percentage points (range: 13% to 40%) * Such as expanding access in health care settings, client reminder and recall systems, clinic-based education, provider education, provider reminder and recall systems, or provider assessment plus feedback Orders.pdf

13 Electronic Standing Orders Work! Study looked at the implementation of an electronic standing orders into the workflow of primary care practices A customized health maintenance template provided SOs for immunization, along with other measures for screening and diabetes. The study showed a median improvement of 8% to 17% in immunizations in participating practices. Best improvement associated with: Established policies and education for staff about new roles Continued reinforcement (staff input, quarterly performance reports). Bulletin boards emphasized the importance of the measures to staff and patients. Variable interest levels by staff and physicians resulted in greater difficulty with implementation Nemeth, Lynne, et al JABFM. 2012; 25, How Do Standing Orders Benefit Medical Practices?

14 Standing Orders in Clinical Practice Efficiency Clinician time is not required to assess vaccination needs and issue verbal or written orders to vaccinate Nurses (or others) take charge of vaccination program Increased number of patients seen = increased income stream Patient safety Improved vaccine coverage, less vaccine-preventable disease Decrease opportunities for VPD transmission in your health care setting What are the Components of a Standing Orders Protocol?

15 Components of a Standing Orders Protocol (1) Who is targeted to receive the vaccine assess the need

16 Components of a Standing Orders Protocol (2) Screen for contraindications and precautions

17 Components of a Standing Orders Protocol (3) Provision of federally required information: the Vaccine Information Statement

18 Components of a Standing Orders Protocol (4) Prepare to administer the vaccine (e.g., by choosing appropriate vaccine product, needle size, and route of administration) Components of a Standing Orders Protocol (5) Specific guidance for administration of the vaccine (e.g., right patient, right vaccine, right age group, right dose, right route and right site)

19 Wrong! Wrong!

20 Correct locations for intramuscular vaccine injections Components of a Standing Orders Protocol (6) How to document vaccination in the patient record

21 Available for purchase on Components of a Standing Orders Protocol (7) A protocol for the management of any medical emergency related to the administration of the vaccine

22 Components of a Standing Orders Protocol (8) How to report possible adverse events occurring after vaccination

23 Components of a Standing Orders Protocol (9) Authorization: In general, standing orders are approved by an institution, physician or authorized practitioner. State law or a regulatory agency might authorize other health care professionals to sign standing orders. So, Standing Orders Protocols for Adult Immunization Are endorsed by major vaccine policy-making institutions Reduce missed opportunities for vaccinating patients Improve vaccine coverage levels in a variety of settings Empower staff Provide more efficient use of clinician expertise Reduce vaccine administration errors by routinizing process, rather than ad hoc implementation Protect your patients and community from vaccine preventable diseases

24 However adult immunizations ARE different from pediatrics IAC study of Implementation of SOPs in 5 practices Recruitment and implementation In 2015 & 2016 IAC created & conducted 26 workshops in 15 states on how to implement SOPs for adult immunization IAC recruited 5 clinics from workshop attendees Sites designed their own process for implementing SOPs Sites determined vaccines and implementation dates

25 Data reporting and site visits Study design Created method for calculating rates that would be compatible with each EMR Aggregate data w/o patient identifiers Baseline 12 months Quarterly reporting during intervention year Site visits Midway through study Interviewed staff Gave educational presentation Quantitative Results very briefly Under SOPs, sites generated modest increases of 4%-8% for most vaccines at most sites But where they were struggling was more interesting

26 Challenges within practices Competing priorities Prioritization of preventive care falls below acute and chronic medical issues Staff barriers Lean, with turnover expected Lack education on adult immunization May have same concerns or misconceptions as the public Vaccine champions needed! Ongoing time and effort needed for: approval, implementation, education, reporting, and cheerleading Challenge immunization history NVAC Standards and CDC recommends documenting immunization history IIS varies by state Data collected inconsistent IIS bi-directionality Varied capacity, affected reporting Lack of easy access to adult vaccination history is a major obstacle Manual history confirmation too time consuming Many providers will not vaccinate w/o history due to financial risk

27 Challenge functionality of EMR Assessing one s own vaccination rates Many have difficulty assessing vaccination rates Seeing one s own rates is important validation Simplifying data transparency is critical Need for flags for vaccine-eligible patients Many EMRs can handle time and age flags for vaccination (if the option is purchased) But risk based factors can be difficult to program And competing priorities for IT can create a barrier Risk based flags were successful Challenge Medicare Part D coverage Physician practices are out-of-network providers Lack access to web-based Medicare Part D billing Patient coverage unknown Copay varies: numerous coverage plans & donut hole Frustration Tdap & zoster aren t covered under Part B Inconsistent and inadequate reimbursement for patients with Part D coverage Providers do recommend Tdap & zoster but Patients don t follow through with getting vaccination at pharmacy Patients not able to afford copays Pharmacies don t always report to IIS https.

28 SOPs ARE INTEGRAL PART OF PLAN TO INCREASE ADULT COVERAGE RATES SOPs for adult immunization Provides structure to reduce missed opportunities of vaccination 1 Creates integration of immunization into procedures, rather than relying on an individual clinician s order for each dose of vaccine 2 Needs additional interventions to prevent immunization fatigue and maintain engagement throughout the year 1. Public Health Rep. 2014;129(2):

29 Adult immunization is different 1/3 fewer ACIP recommended vaccines for adults than children 32 vs. 11, excluding influenza Longer intervals between doses Less time to provide preventive care Reimbursement for Medicare Part D covered vaccines Incentives are lacking adult immunization needs to be included within quality improvement metrics In conclusion Adult VPDs continue to be a morbidity, mortality and cost burden in the United States. Coverage rates for ACIP-recommended vaccines are unacceptably low. Implementing SOPs will improve practice efficiency and increase coverage rates and so should be considered as the foundation for an adult immunization program in a practice. However, in adult practices, additional interventions may be required to sustain increased immunization rates Some challenges beyond the reach of individual practices SOPs should be part of a plan to increase adult immunization coverage rates

30 New! Standing orders protocols webinar series From IAC, IDCareLive.com and Pfizer Visit IAC/Summit Resources! Use our publications! Visit our websites! Stay ahead of the game! Subscribe to our updates!

31 Thank You!

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