Evaluation of Immunization Standing Orders Programs in North Carolina Hospitals Presented by Wayne L. Anderson Ph.D.1, Amanda Honeycutt Ph.D.1, Kathleen Wirth1; Margaret S. Coleman Ph.D.2 1RTI International; 2CDC Presented at CDC National Immunization Conference Washington, DC, March 23, 2005 Focus of our study is on the hospital setting. The study was funded last fall and we began working with hospital associations in NC, GA, and DC soon after. 3040 Cornwallis Road ■ P.O. Box 12194 ■ Research Triangle Park, NC 27709 Phone 919-541-6998 Fax 919-541-6683 E-mail: wlanderson@rti.org RTI International is a trade name of Research Triangle Institute

Background—Strategies to Improve Adult Vaccination Coverage Rates Task Force on Community Preventive Services (CDC, 1999) recommended Standing orders programs (SOPs) Other provider-based strategies (e.g., PPO & PR) In 2000, the Advisory Committee on Immunization Practices (ACIP) recommended SOPs Effectiveness of SOPs has been studied in individual hospitals, but cost-effectiveness has seldom been studied, and never across multiple hospitals before SOPs recommended for adults in hospitals and other health care settings. Bratzler figures are from before the recommendations. Suggests is a good opportunity to vaccinate people at high risk who otherwise might not get the vaccine.

Study Purpose To estimate the cost-effectiveness of immunization standing orders in the hospital setting Fairly diverse sample of hospitals from North Carolina. ID’d through the help of the NC hospital association. Labor and other resource data used to estimate program costs from the hospital perspective. Focused on 5 activities that are part of most hospital-based immunization programs.

Methods—Cost Data Collection Convenience sample 10 North Carolina hospitals 40% urban, 50% teaching, and 60% > 200 beds All nonprofit Collected data on labor and resources Program activities included High-risk and age screening Vaccine eligibility determination Ordering and storage Administration Recordkeeping Fairly diverse sample of hospitals from North Carolina. ID’d through the help of the NC hospital association. Labor and other resource data used to estimate program costs from the hospital perspective. Focused on 5 activities that are part of most hospital-based immunization programs.

Methods—Program Effectiveness Vaccination coverage rates estimated from NC hospitals Coverage rate definition: Numerator = number of vaccine orders Denominator = estimated number of patients eligible for influenza or pneumococcal vaccine Eligible defined as those at “high risk” excluding those with prior vaccination or contraindication Effectiveness was estimated from studies in the literature because we didn’t have the resources needed to collect effectiveness data from hospitals. We did get some information from the hospitals that participated which allowed us to estimate their coverage rates and to compare to rates from the literature. Definitions: SOP = non-physician medical personnel prescribe or deliver vaccine w/o direct physician involvement and according to hospital protocol. PPO = non-physician staff screen new hospital admits to ID high risk and place an unsigned vaccination order in charts PR = non-physician staff screen for high risk and place a note in charts to remind MDs to determine vaccine eligibility Control = no formal program; vaccination occurs at random.

Methods—Cost Estimation Program cost per person screened equals Total cost ÷ Number of people screened, where total cost is calculated as Cost of Screening x Cost to ID High Risk x Cost to ID Elig x Ord Cost x Adm Cost x Rec Cost x + + + + + Cost of screening * number screened + cost of identifying high risk * number at high risk, etc. Number Screened Number at High Risk Number Eligible Number Ordered Number Admin-istered Number Recorded

Estimated Effectiveness: Vaccination Coverage Rates in NC Hospitals Program Type Number of Programs Range of Effectiveness Mean Effectiveness SOP 5 (0.215 – 0.60) 0.432 PPO 3 (0.036 – 0.222) 0.119 PR (0.075 – 0.85) 0.393 Rates found among hospitals in our study were similar: SOP rate was 51% and average non-SOP rate was 35%. May reflect difference between effectiveness as measured in a controlled research environment v. when measured in the “real world”.

Estimated Effectiveness Results—Incremental Cost-effectiveness of SOPs vs. non-SOP interventions Program Type Estimated Cost ($) Estimated Effectiveness Comparison SOP 4.50 0.432 — (2.67 – 7.96) (0.22 – 0.60) PPO 6.03 0.119 SOP is cost-saving v. PPO (2.59 – 11.07) (0.04 – 0.22) PR 6.04 0.393 SOP is cost-saving v. PR (3.94 – 8.70) (0.08 – 0.85) SOPs cost less and achieve higher coverage rates on average than non-SOP intervention programs in hospitals. They dominate the intervention alternatives and are said to be “cost saving”.

Limitations Geography Attempts were made to include 3 other states NC culture—delegation of authority to pharmacists and NPs Analysis from hospital perspective, not societal SOPs are illegal in CA, and the few GA hospitals that were doing something to improve vaccination coverage rates felt overburdened by existing research and didn’t want to participate. About ½ of studies in the literature concerned one or the other vaccine, but all but one of our hospitals had a program in place for both flu and pneumo. Analysis was from the hospital perspective v. societal.

Conclusions SOPs are cost-saving (CER of $10) when compared to PRs and PPOs “Simple” community-based programs are not simple to implement because of variations across hospitals SOPs appear to be a promising and cost-effective strategy for increasing vaccination rates among high-risk and elderly hospitalized patients (compare to reimbursement and estimated flu costs) More study is needed to say for certain whether $22 per person vaccinated in the hospital is “cost-effective” Hospitals that used PR or PPO approaches could enjoy savings and vaccinate more patients by switching to an SOP program. The high risk groups targeted by such hospital programs are those most likely to experience severe morbidity or death from flu or pneumo