A Missed Opportunity

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A Missed Opportunity
Inpatient Immunizations
Wednesday December 4, 2002 200 300
PM(EST) Or Thursday December 5, 2002 1000
1100 AM(EST)
3 Call-in Number 1-800-441-0022
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Housekeeping Items

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How Do Ohio Hospitals Compare with the Best
States?
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Influenza Vaccination in Ohio
1580 Total CAP admissions - 106 Discharged
(died, Transferred, AMA) 1474 Eligible cases
in Denominator -1258 Missed Opportunities 216
(14.7) Patients were vaccinated
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Pneumonia Vaccination In Ohio
1580 Total CAP admissions - 106 Discharged
(died, Transferred, AMA) 1474 Eligible cases
in Denominator -1360 Missed Opportunities 114
(7.7) Patients were vaccinated
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Missed Opportunities In Ohio
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Failure to Vaccinate Medicare Inpatients
A Missed Opportunity

• Dale W. Bratzler, DO, MPH
• Peter M. Houck, MD
• Hui Jiang, MS
• Wato Nsa, MD, PhD
• Claudette Shook, RN
• Lori Moore, RN
• Lisa Red, MSHA
• 
  Oklahoma Foundation for
  Medical Quality, Inc., Oklahoma City, OK.
• Centers for Medicare Medicaid Services,
  Seattle, WA.

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Missed OpportunitiesBackground

• Influenza and pneumococcal vaccines are
  underutilized.
• 1999 BRFSS, age 65 years and older
• 66.9 received the influenza vaccine
• 54.1 had received the pneumococcal vaccine

CDC. MMWR. 200150532-537.
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Missed OpportunitiesBackground

• Underutilization is not without consequences
• influenza causes more than 100,000 excess
  hospitalizations and 20,000 deaths each year.
• S. pneumoniae infection accounts for at least
  500,000 cases of pneumonia and 50,000 cases of
  bacteremia each year.

CDC. MMWR. 200150 (No. RR-4) 1-46. CDC. MMWR.
199746(No. RR-8)1-24.
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Deaths Due to Vaccine Preventable Diseases - US,
1989-1998
320k 520k (85 in elderly)
11k (reported cases)
MMWR 2001 48 (RR-53) Data for influenza
pneumococcal diseases are estimates, data for
other diseases are reported cases.
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Missed OpportunitiesBackground

• The combined reporting category of influenza and
  pneumonia represents the 5th leading cause of
  death for this age group.

Minino AM, Smith BL. Preliminary data for 2000.
National vital statistics reports vol. 49, No.
12. Hyattsville, Maryland National Center for
Health Statistics. 2001.
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Missed OpportunitiesBackground

• Up to 46 of subsequent influenza-related
  hospitalizations and 2/3 of influenza related
  deaths occur in elderly who have been previously
  hospitalized during flu season.

Infect Control Hosp Epidemiol. 200021692-699.
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Missed OpportunitiesBackground

• Up to 2/3 of patients hospitalized with serious
  pneumococcal infections have been previously
  hospitalized at least once during the previous
  3-5 years.

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Missed OpportunitiesBackground

• Despite the risk of subsequent disease,
  immunization status is often not documented and
  vaccination is rarely offered to hospitalized
  patients.

Fedson DS, et al. Infect Control Hosp Epidemiol.
200021692-699. CDC. MMWR. 199746919-923. Meter
sky ML, et al. Am J Med. 2001110141-143. Dexter
PR, et al. N Engl J Med. 2001345965-970.
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Missed OpportunitiesBackground
CDC. MMWR. 199746919-923.
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Missed OpportunitiesBackground
CDC. MMWR. 199746919-923.
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Vaccine Effectiveness

• Influenza vaccine (Flu shot)
• 40-50 effective at preventing hospitalization
• 80 effective in preventing death
• Pneumococcal vaccine
• up to 75 effective at preventing invasive
  disease
• A vaccine not given is 100 ineffective!

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Missed OpportunitiesMethods

• Structured medical record review of
  fee-for-service Medicare inpatients with one of
  four conditions.
• Systematic random sample (up to 850 cases per
  state per topic).

Bratzler DW, Houck PM, et al. Arch Intern Med.
20021622349-2356.
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Missed OpportunitiesMethods

• Analysis limited to patients aged gt 65 discharged
  alive from the hospital.
• Inpatient data linked to Medicare influenza and
  pneumococcal billing data (Part B).

Bratzler DW, Houck PM, et al. Arch Intern Med.
20021622349-2356.
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Missed OpportunitiesResults

• 144,482 hospitalizations
• Exclusions
• 8,508 diagnosis-specific
• 10,756 patients lt 65 years of age
• 15,451 died in the hospital
• 109,767 hospital discharges
• 107,311 unique patients
• 104,976 patients with a single admission
• 2,335 patients with more than one admission

Bratzler DW, Houck PM, et al. Arch Intern Med.
20021622349-2356.
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Missed OpportunitiesInfluenza vaccine
Medicare patients aged gt 65 years discharged
alive from the hospital between October 1 and
December 31, 1998. Prior based on Medicare
claims analysis or medical record abstraction for
1998 flu season. After discharge based on
Medicare claims analysis through January 31, 1999.
Bratzler DW, Houck PM, et al. Arch Intern Med.
20021622349-2356.
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Missed OpportunitiesPneumococcal vaccine
Medicare patients aged gt 65 years discharged
alive from the hospital between July 1, 1998, and
March 31, 1999. Prior based on Medicare claims
analysis (Part B data back to 1991) or medical
record abstraction. After discharge based on
Medicare claims analysis for one month after
dismissal.
Bratzler DW, Houck PM, et al. Arch Intern Med.
20021622349-2356.
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Missed OpportunitiesResults
Bratzler DW, Houck PM, et al. Arch Intern Med.
20021622349-2356.
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Missed OpportunitiesComments

• Hospital-based vaccination of adults has been
  recommended since the 1980s.
• ACIP, ACP, APIC, NVAC, AHA, ATS, IDSA
• Patients not vaccinated in the hospital often are
  not vaccinated after discharge.

Bratzler DW, Houck PM, et al. Arch Intern Med.
20021622349-2356.
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Missed OpportunitiesComments

• If we apply BRFSS vaccination rates to this
  population of patients
• 13,402 never received the influenza vaccine
• 48,184 did not receive PPV
• Extrapolated to the 12,683,000 hospital
  discharges of patients age 65 years and older
  annually in US - millions not immunized.

Bratzler DW, Houck PM, et al. Arch Intern Med.
20021622349-2356.
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Missed OpportunitiesComments

• Factors to explain lack of effective
  hospital-based vaccination programs
• skepticism about vaccine efficacy
• concern about reimbursement
• concern about safety in hospitalized patients
• lack of a systems-based approach

Bratzler DW, Houck PM, et al. Arch Intern Med.
20021622349-2356.
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Missed OpportunitiesVaccine Efficacy

• Influenza vaccine is immunogenic in hospitalized
  patients and patients with chronic renal failure.
• Pneumococcal vaccine approximately 60 effective
  preventing invasive disease.

Berry BB et al. Vaccine. 2001193493-3498. Brydak
LB et al. Vaccine. 2000183280-3286. Christenson
B, et al. Lancet. 20013571008-1011. Nichol KL,
et al. Arch Intern Med. 19991592437-2442. Nichol
KL. Vaccine. 199117(suppl 1)S91-S93.
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Missed OpportunitiesVaccine Safety

• Many hospital and emergency department-based
  vaccination programs have been safely and
  effectively implemented with no evidence of
  significant risk.

Klein RS, et al. Arch Intern Med.
19831431878-1881. (hospital pneumococcal
vaccine) Magnussen CR, et al. Arch Intern Med.
19841441755-1757. (hospital and ambulatory
pneumococcal vaccine) Bloom HG, et al. J Am
Geriat Soc. 198836897-901. (hospital influenza
and pneumococcal vaccines) Crouse BJ, et al. J
Fam Pract. 199438258-261. (hospital-based
influenza vaccination) Nichol KL, et al. Am J
Med. 1998105385-392. (10-year experience with
inpatient influenza and pneumococcal
vaccination) Rodriquez RM, et al. Ann Emerg Med.
1993221729-1732. (ER-based influenza and
pneumococcal vaccination) Slobodkin D, et al.
Vaccine. 1998161795-1802. (Inner-city ER-based
influenza and pneumococcal vaccination)
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Missed OpportunitiesSystems-based Interventions

• Implementation of system-based strategies such as
  standing orders programs will be necessary to
  increase vaccination of this high-risk population.

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Standing Orders Programs

• Standing orders programs authorize nurses or
  pharmacists to administer vaccinations according
  to an institution- or physician-approved protocol
  without a physicians examination.

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Standing Orders ProgramProtocol for
Implementation
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Standing Orders are Among the Most Effective
Strategies

• Non-physicians offer and administer vaccinations
  without direct doctor involvement at the time of
  the visit
• Established through approved policies protocols
• Locations clinics, hospitals nursing homes

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Success of Standing Orders as Part of a
Multifaceted Program
Standing Orders
Education
Nichol KL. Am J Med 1998 105 385.
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Federal Register. Vol. 67, No. 191. Pp
61808-61814. October 2, 2002
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Institutional VaccinationNew Medicare Regulation

• Federal Register, Vol. 67, No. 191 (October
  2, 2002)
• All orders for drugs and biologicals must be in
  writing and signed by the practitioner or
  practitioners responsible for the care of the
  patient as specified under 482.12(c) with the
  exception of influenza and pneumococcal
  polysaccharide vaccines, which may be
  administered per physician-approved facility
  policy after an assessment for contraindications.
  
• Includes similar provisions for nursing homes and
  home health agencies.

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Missed OpportunitiesConclusions

• Despite national recommendations for
  hospital-based immunization, Medicare inpatients
  often do not receive indicated influenza and
  pneumococcal vaccines.

Bratzler DW, Houck PM, et al. Arch Intern Med.
20021622349-2356.
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www.nationalpneumonia.org
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Steps to Bill Medicare for Inpatient Immunizations

• Mary Courtney
• Action Plan Coordinator
• AdminaStar

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Your Questions
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