Adult Immunization, Patient-Centered Medical Care, and the Primary Physician

Transcription

1 Adult Immunization, Patient-Centered Medical Care, and the Primary Physician John H. O Neill, Jr., D.O., FACP Bayview Internal Medicine, Inc., Middletown, Delaware Chair, Immunization Technical Advisory Committee, ACP NJ Adult Immunization Summit November 4, 2015, Princeton 1

2 Disclosure Dr. John O Neill has received a stipend from ACP to assist in the development of educational programs and tools to promote adult immunization, and otherwise has NO financial relationships with any entity producing, marketing, re-selling, or distributing health care goods or services, consumed by, or used on, patients. 2

3 Objectives Briefly Review the Immunizationsthat are indicated for adult patients in 2015 Explore team-based strategies for providing efficient and automated, patient-centered adult immunizations in the Primary Medical Practice Touch on some important Cost considerations 3

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5 The Big Five for Adults Influenza Td/Tdap PCV13 (conjugated pneumococcal) PPSV23 (pneumococcal polysaccharide) Zoster (VZV) 5

6 The Other Seven for Adults: individual circumstances HPV2/HPV4/HPV9 Meningococcal Hepatitis B Hepatitis A MMR Varicella Hib 6

7 NHIS 2013, non-flu immunization Immunization Age range % Received Source: cdc.gov/mmwr/preview 2/6/15 Pneumococcal >65 Tetanus >65 Tetanus/Pertussis >65 Hepatitis B With hx DM (+2.9%) Zoster > (+4.1%) HPV (female) female male (+5.3%) 7

8 US Adult Immunization Rates are Unacceptably Low! Source: 8

9 ACIP 2015: Influenza Annual influenza vaccination is recommended for all persons > 6 months of age If hives-only egg allergy, ok to give IIV (age-approp.) Recombinant influenza vaccine (RIV) can be given to persons > 18 if hxegg allergy of any severity LAIV: ages 2-49, an option for healthy, non-pregnant Intradermal IIV is an option for ages Pt s > 65 can receive standard or high dose IIV 9

10 Some Types of Flu Vaccines: CPT code MCR Q code Vax Type Brand Name (18-64 y/o) IIV3 Fluzone intraderm (preservative free) IIV3 (pf) Fluzone, Fluvirin, Fluarix, Afluria 90658* Q2035 IIV3 Afluria 90658* Q2037 IIV3 Fluvirin 90658* Q2038 IIV3 Fluzone cell culture, no egg cciiv3 Flucelvax (preservative free) IIV3hd Fluzone-HiDose (2-49 y/o) LAIV4 FluMist 90673* (18 y/o and up) Q2033 RIV3 FluBlok (quadriv, pres free) IIV4 (pf) FluZone (quadriv) IIV4 FluLaval, Fluzone 10

11 Avian.gif 11

12 ACIP 2015: Td/Tdap Administer 1 dose of Tdapto pregnant patients in 3 rd trimester, with eachpregnancy Persons >10 y/o, give Tdapif not given previously or if unsure of hx, then Td every 10 yrthereafter Adults with no known hxof primary series should receive a 3-shot series, one of them being Tdap, the other 2: Td, at months 0, 1 and 6 For wound, post-exposure prophylaxis, can use Tdapif not given previous and last Td > 9 yrs 12

13 ACIP 2015: Pneumococcal PCV13, once for all persons 65 and up (if not before) PPSV23, give one year after PCV13 If PPSV23 already given, PCV13 should be given not sooner than 12 months after PPSV23 For < 65 y/o: PCV13 once, then PPSV23 (1 yrlater, and boost in 5 yr), for nephrotic, immunosuppressed pt s, and those w/ cochlear implant or CSF leak, and functional/anatomic asplenia For < 65 y/o: PPSV23 once for above, also smokers, long term care residents and for chronic heart, lung, liver, kidney disease/diabetes; can boost in 5 yrfor higher risk patients 13

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15 ACIP 2015: Zoster Once after age 60, SQ injection, without regard for previous Zoster (> 1yr) or Varicella Hx Live attenuated virus, avoid in pregnant or immunosuppressed Store in freezer (-58 to +5 degrees F, -50 to -15 C) About 50% effective in preventing Zoster Reduced severity of Zoster (pain) by 66% in those who developed Zoster subsequent to having received the vaccine 15

16 Vaccines, Cost and Reimbursement vaccine cpt Icd10 Approx. Cost* (*VCF) Est. Private Sector reimb. Mcr (DE ) reimb. Influenza (pres. free) Z Influenza (IIV3) Z Influenza (hi dose ag, > 65 y/o) Z Influenza quadrivalent (pf) Z PPSV Z Tdap Z Herpes Zoster Z PCV Z Hepatitis B Z Meningococcal (conj.) Z HPV (9 valent) Z

17 Vaccine Administration Vaccine MCR (HCPCS) MCR Pmt (DE ) PAR Non-MCR CPT Private Sector reimburse Influenza G Pneumococcal G Hepatitis B G Second Vax Admin per day Administer Vax <age 18, with counselling (use icd9 V06.6 if flu vax and PPSV23 given same day) ,

18 Team-based Immunization Pre-visit planning: (receptionist and MA/RN) identify scheduled patients Charts are pulled to identify deficits and opportunities for vaccination Standing Orders: Immunization Action Coalition Patient receives needed vaccine after rooming and prior to physician seeing them Post-visit intervention: PM system reporting identifies patients who have not been in for a defined interval, charts pulled, opportunities for vaccination id d, patients contacted 18

19 Vaccine Storage 19

20 Other cost considerations: Digital Thermometers: Vaccine refrigerators: consider thermo.com, fischersci.com, sunfrost.com, labresprod.com Storage and handling of vaccines: best practices Vaccine DiscountSuppliers: ***buying vaccines for less $$$(eg. Vaxserve.com, AHP: atlantichealthpartners.com, and NVDA: nationaldiscountvaccinealliance.com) **see also AAP web site 20

21 Thank you! 21