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