Increasing (Late Season) Influenza Vaccinations- Baton Rouge

William Cassidy, MD

Louisiana State University

Health Sciences Center

Acknowledgements

• LSU– Dale Marrioneaux– Aubrey Lipham– Sal Baghian– Baton Rouge General

Staff– Our Lady of the Lake

Staff

• CDC– Dan Fishbein– Susan Manning– Edith Gary

Outline

• Question

• Reasons for low immunization rates

• Phases of “Baton Rouge” Effort

– Isolating variables

– Results

• Conclusions

Question

Are reasons for decreased late season

flu immunization different from reasons

for decreased early season flu

immunization.

Outline

• Question

• Reasons for low immunization rates

• Phases of “Baton Rouge” Effort

– Isolating variables

– Results

• Conclusions

Patient Reasons to be Un-Vaccinated

• Inadequate Knowledge, Attitudes & Practices (KAP)

– knowing, caring or wanting

• Expense

– Direct cost of vaccine & MD visit

– Indirect cost of missing work

Providers Reasons to not Vaccinate

• Inadequate Provider KAP

– Non traditional providers (ex. ER Docs)

– Extension of vaccination season

• Direct and Indirect “Costs”

– Cost of vaccine and vaccination

– Counseling can be very time consuming

Outline

• Question

• Reasons for low immunization rates

• Phases of “Baton Rouge” Effort

– Isolating variables

– Results

• Conclusions

ChangesKAP Direct

Cost

Indirect

Cost

Patient $0

Provider $0

Phase 1 of 4, Assessment/Reminder forms for 6 vaccines in 3 Primary Care Settings

Conclusions: Providers did not give recommended vaccines, unable to assess effect of increasing patient KAP

Results: No significant increase in immunizations in the intervention group.

ChangesKAP Direct

Cost

Indirect

Cost

PatientA/R

FORM$0

ProviderStanding Orders, Provider not

involved

Phase 2 of 4

Para-professionals approached ED patients,

Immediate vs. Later Vaccination

Phase 2: Indirect Cost to Patients

• Results - Immediate vaccination with greater acceptance rate.

• Conclusions – Eliminating patient’s indirect costs significantly increases vaccination coverage

• Note: Provider role eliminated

ChangesKAP Direct

Cost

Indirect

Cost

PatientA/R

FORM$0, 5, 10

$0

Provider + Provider signed standard order

Phase 3 of 4, Para-professionals Using A/R Forms,

Patients Randomized to $0, $5, $10 Co-pay

Phase 3: Varied Patient Direct Costs

• Results

– Incremental increases in a patient’s direct cost decreased vaccination acceptance

• Conclusions –

– ED immunization facilitated by para-professionals feasible

• Note: Providers minimally involved

ChangesKAP Direct

Cost

Indirect

Cost

PatientA/R

FORM$0 $0

Provider $0

Phase 4a of 4, City Wide Effort:

Para-professionals Using A/R Forms,

Providers signing standard orders

Results: Anomalous year

Larger ED with better cost benefit ratio

Phase 4b, Baton Rouge Efforts

• November 2005 – March 2006

• Larger hospital assessed 24/7

• Smaller hospital assessed 10 A to 10 P

• Physicians signed standard orders

• Nurses vaccinated

ChangesKAP Direct

Cost

Indirect

Cost

PatientA/R

FORM$0 $0

Provider $0

Phase 4b of 4, Para-professional - A/R

Forms, Providers signing standard orders

2 Busiest Emergency Departments

Racial Disparities

AA AA Vax

Rate

Non

AA

Non AA Vax Rate

P Value

Screened 1729 556

ACIP risk 1332 427

UTD 375 28.2% 196 45.9%

Vaccinated 326 24.5% 81 19.0%

Total coverage 52.6% 64.9%

Influenza Vaccination, Patients in ACIP Risk Groups by Race, Hospital A ED, Dec. 5-Feb. 16

375196

0%

20%

40%

60%

80%

100%

Black Non-black

Already vaccinated*

*

Influenza Vaccination, Patients in ACIP Risk Groups by Race, Hospital A ED,

Dec. 5-Feb. 16

375196

483

99

0%

20%

40%

60%

80%

100%

Black Non-black

Accepted vaccination

Already vaccinated

Question

Are reasons for decreased late season

flu immunization different from reasons

for decreased early season flu

immunization.

Late Season Immunization

No significant decrease in late and

early season acceptance of flu

immunization

Patient Reasons to be Un-Vaccinated

• Inadequate Knowledge, Attitudes & Practices (KAP)

• Direct and Indirect “Costs”

Providers Reasons to not Vaccinate

• Inadequate Provider KAP

• Direct and Indirect “Costs”

Overall Conclusions

• Para-professionals in EDs can increase patient’s KAP towards flu vaccination

• Eliminating patient’s direct & indirect cost increases immunization rates

• ED immunization decreases disparities

• Providers: Role is problematic

Conclusions of Phase 4b

• Late flu season immunization is feasible and accepted by patients.

• Patient issues with late flu immunization are the same as early season issues

• Provider issues may be important

Outline

• Question

• Reasons for low immunization rates

• Phases of “Baton Rouge” Effort

– Isolating variables

– Results

• Conclusions