Improving Immunization Rates For Seniors in Long-Term Care: The CDC/CMS Immunization Standing Orders Project Dale W. Bratzler, DO, MPH Principal Clinical Coordinator Oklahoma Foundation for Medical Quality, Inc.

Documented Influenza and Pneumococcal Vaccination, 1995-1999 National Nursing Home Survey Buikema AR, Singleton JA, et al. [abstract] Centers for Disease Control and Prevention, 35th National Immunization Conference.

They are underutilized! Vaccination Reality Despite the fact that the influenza and pneumococcal vaccines are clinically effective cost effective safe free to most elderly patients Healthy People 2010 goals of 90% vaccination rates They are underutilized!

The CDC/CMS Immunization Standing Orders Project Collaborative effort between the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare & Medicaid Services (CMS) Measurement and intervention implemented through the Medicare QIO Program (formerly, Peer Review Organizations)

SOP Steering Committee CDC Abigail Shefer (PI) Linda McKibben (Co-PI) Paul Stange OFMQ Dale Bratzler Jennifer O’Hagan Lori Moore Kathy Hankey CMS Jackie Harley Kathy Pirotte Peter Houck QIO Representative Kurt Stevenson

Overall Goal of the SOP To increase coverage rates for pneumococcal and influenza vaccines in long-term care facilities through the use of standing orders programs

Standing Orders Programs Standing orders programs authorize nurses or pharmacists to administer vaccinations according to an institution- or physician-approved protocol without a physician’s examination Standing orders programs empower nurses or pharmacists to screen patients for vaccine status and, when indicated, to administer the vaccines according to the institution- or physician-approved protocal without the need for the individual physician examination. In studies reported at this conference, vaccination protocols that require the individual physician examination or actual written order are not as effective as programs that empower the nurse or pharmacist to offer the vaccine by protocol. Standing orders programs have three components: 1) Infrastructure components (policy statement, information systems, quality assurance systems, personnel, etc.) 2) Service Delivery components 3) Vaccine ordering mechanism

District of Columbia Intervention States Control States

Standing Orders Project Methods Short survey (N = 2,065) 20 LTCs in each state (N = 280) Based on facility size, influenza program type, and QIO* participation Long survey and coverage data completed at same facilities Cost survey completed in a subset *Not used for selection in control States

Vaccination Coverage SOP Project, Baseline: 2000-2001 N = 277 LTCs (21,624 residents)

Vaccination Policies and Procedures for Residents N = 249 LTCs, Long Survey

Vaccination Policies and Procedures for Staff N = 249 LTCs, Long Survey

Barriers to Immunizing Residents N = 249 LTCs, Long Survey

Barriers to Implementing Standing Order Programs

Tracking and Documentation of Vaccination N = 249 LTCs, Long Survey

Immunization Program Types Survey Definitions Usual Care - individual physician order Reminders (R/R) - remind physician or residents Preprinted Admission Order (PPAO) - Standardized forms placed in chart for physician signature Advanced Physician Order (APO) - physician authorizes vaccination of their patients Standing Order (SOP) - authorizes immunization of all residents by institutional policy

Type of Immunization Program Short Survey N = 1,598 LTCs in 7 intervention states with complete survey and OSCAR data

Flu Program Type and Coverage Long Survey and Coverage Data (N = 249) Usual (n=53) APO (n=35) PPAO (n=58) R/R (n=57) SOP (n=44) Program Type *Median and 25/75 percentile

Pneumococcal Program Type and Coverage (N = 249) Usual (n=118) APO (n=17) R/R (n=52) PPAO (n=36) SOP (n=24) Program Type *Median and 25/75 percentile

Influenza Program Cost Estimates, by Activity *Based on 10 observations Standard deviations

Interpretation of Influenza Results Cost Survey and Coverage Incremental Effectiveness of SOP compared to alternative interventions More Same Less Incremental Cost of SOP compared to alternative interventions More Same Less Accept SOP over PPAO, RR, and APO RTI, International Strong dominance for acceptance/rejection Weak dominance for acceptance/rejection No obvious decision without further analysis

Vaccination and Outcomes Preliminary data - hospitalization* *Hospital stays with a discharge date between November 1, 2000, and April 30, 2001.

Vaccination and Outcomes Preliminary data - mortality* *All-cause mortality between November 1, 2000, and April 30, 2001.

Vaccination in Nursing Homes A Unique Opportunity to Improve There are approximately 1.5 million residents living in more than 17,000 nursing homes in the US* Preventing adverse events in this population will require systems-based interventions to ensure quality care *American Health Care Association