Presented at The 129th Annual Meeting of the American Public Health Association Atlanta, GA, October 21

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Immunization Standing Orders Program Project
Costs and Cost-Effectiveness in LTCs

• Presented at The 129th Annual Meeting of the
  American Public Health Association Atlanta, GA,
  October 2125, 2001
• Presented by Amanda Honeycutt Abigail Shefer
• Linda McKibben Jeanne Krider

P.O. Box 12194 3040 Cornwallis Road Research
Triangle Park, NC 27709Phone [phone]
Fax [phone] honeycutt_at_rti.org
www.rti.org
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Background on the Standing Orders Program (SOP)
Project

• CDC and CMS are collaborating to promote
  influenza and pneumococcal vaccines in LTCs
  through the use of SOPs
• SOPs are policies that allow non-physician staff
  to vaccinate without direct physician
  involvement, such as a signed physicians order
• CMS peer review organizations (PROs) in 9 states
  are participating in the SOP project
• PROs provide model programs and other resources
  to assist LTCs in adopting SOPs

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Study Objectives

• To estimate the costs of implementing SOPs for
  immunization in LTCs
• To estimate ongoing immunization program costs
  for LTCs with SOPs compared to those with other
  types of immunization programs
• If SOPs are associated with higher vaccination
  rates relative to other immunization program
  types in LTCs
• To evaluate the cost-effectiveness of SOPs by
  comparing differences in ongoing costs for LTCs
  with SOPs versus other immunization programs and
  differences in facility vaccination rates

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Previous Analyses--Effectiveness of SOPs

• SOPs have been shown to be an effective means of
  raising immunization coverage rates for adults
  (see e.g., Klein and Adachi 1986 and Nichol
  1991)
• The Guide to Community Preventive Services
  strongly recommends SOPs as a provider-based
  intervention for adults

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Previous Analyses--Costs of Provider-Based
Interventions

• Rosser et al. (1992) estimated that the costs of
  physician, telephone, and letter reminder
  programs were 0.43 to 6.05 per additional
  vaccine
• Study assessed costs and outcomes for tetanus
  vaccines
• For SOPs, no previous cost analyses or economic
  evaluations are available in the published
  literature

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Methods Cost Data Collection

• Visited 5 LTCs to observe the immunization
  process
• identified key differences in the process for
  LTCs with SOPs compared to those with pre-printed
  admission orders, reminder/recall, or no
  immunization program
• Data collection through self-administered
  questionnaires
• Collected data on program start-up efforts and
  costs, staff and non-facility staff time required
  for the vaccination process, staff wage
  rates/salaries, and materials used
• Mailed to 36 LTCs (4 in each of 9 INT states)
• PROs requested participation during phone calls
  and mailed questionnaires to each LTC

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Methods Effectiveness Data Collection

• Surveys about facilities immunization policies
  and practices
• Conducted by CDC
• Mailed to all participating facilities in
  intervention states and a randomly selected
  sample of facilities in control states
• Used to identify immunization program type for
  each LTC
• Chart Data Abstraction
• For up to 100 randomly selected residents in LTCs
  in both intervention and control states
• Used to determine vaccination coverage rates for
  each facility for influenza and pneumococcal

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Methods Data Analysis (I)

• Cost estimation
• Ongoing costs estimated from the LTC and societal
  perspectives
• Per-resident cost estimates were generated for
  the following components
• Reminder program
• Eligibility determination
• Follow-up with MDs to obtain order
• Vaccine administration, and
• Tracking receipt of the vaccine

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Methods Data Analysis (II)

• Cost estimation
• Mean estimated costs calculated for 5 different
  program types
• SOPs,
• Preprinted admission orders (PPAO),
• Reminder/recall (RR),
• Advanced physician orders (APO), and
• Usual care (no organized program)
• Estimation of program effectiveness
• Mean and median estimated immunization coverage
  rates calculated for each program type

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Results Flowchart Analysis of Immunization
Program Activities
Typical Activities under a Standing Orders Program
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Results Differences in LTC Immunization
Activities by Program Type
Typical Reminder/Recall Program
Typical Standing Orders Program
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Results Response Rates for Cost Questionnaire

• 19 of the 36 questionnaires were returned with
  complete responses
• Response rate of 53
• Reasons for the low response rate
• Short time to complete the questionnaire--LTCs in
  3 of the states were given about 1 month to
  complete
• No incentives were provided to respondents
• Cost data collection occurred at the same time as
  other intensive data collections (e.g., surveys,
  resident chart abstractions) in each facility
• Many of the LTCs experienced turnover in key
  staff (e.g., Directors of Nursing)

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Results Cost Estimates

• Ongoing costs of SOPs v. alternative immunization
  programs

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Results Estimated Influenza Immunization
Program Rates

• Flu vaccination coverage rates for SOPs v.
  alternative immunization programs

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Interpreting Results
Incremental Effectiveness of SOP compared to
alternative interventions
More
Same
Less
More
Incremental Cost of SOP compared to alternative
interventions
Same
Accept SOP over PPAO, RR, and APO
Less
Strong dominance for acceptance/rejection Weak
dominance for acceptance/rejection No obvious
decision without further analysis
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Cautionary note about interpreting results

• More analyses are needed to determine whether
  facilities with SOPs have statistically
  significantly higher vaccination coverage rates
• Assessment of the mean differences in
  effectiveness for the full sample of facilities
• Multiple regression analysis to control for other
  factors that may be associated with immunization
  coverage rates, such as
• Facility size
• Ownership (chain/no-chain)
• For-profit v. not-for-profit

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Study Limitations

• Small sample size
• Only 18 LTCs returned cost questionnaires for
  influenza immunization programs
• However, good representation in terms of
  immunization program type and facility size
• Outcomes considered are intermediate as opposed
  to final outcomes, such as the number of cases of
  influenza-related hospitalizations and deaths
• Effectiveness estimates are not statistically
  significant for the small sample that
  participated in cost analyses

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Summary and Conclusions

• Findings suggest that SOPs strongly dominate
  alternative immunization programs for influenza
  in LTCs in terms of their cost and vaccination
  coverage rates
• Findings indicate that SOPs can lead to savings
  of 79 per additional vaccine recorded as
  compared to PPAOs and 98 per additional vaccine
  recorded as compared to RRs
• Additional analyses of the relationship between
  immunization program type and coverage rates are
  needed (and planned) to determine whether these
  findings are representative