Adolescent Immunization in Primary and Alternative Settings, and Health Care Utilization Peter G. Szilagyi MD MPH Department of Pediatrics University of Rochester School of Medicine and Dentistry

Who are these people? Why are they important for adolescent immunizations?

Outline Where should adolescents be vaccinated? Primary care Other settings What should change in primary care settings? What are the benefits of adolescent vaccination? We focus on two major research questions: We study methods to improve immunization delivery, particularly for poor children or those with chronic conditions. Second, we study implementation of new vaccines, using a “benches to trenches” approach. Studies include basic laboratory work to identify viruses, clinical investigation to measure disease burden, and health services research to study how best to deliver new vaccines.

Outline Where should adolescents be vaccinated? Primary care Other settings What should change in primary care settings? What are the benefits of adolescent vaccination? We focus on two major research questions: We study methods to improve immunization delivery, particularly for poor children or those with chronic conditions. Second, we study implementation of new vaccines, using a “benches to trenches” approach. Studies include basic laboratory work to identify viruses, clinical investigation to measure disease burden, and health services research to study how best to deliver new vaccines.

Definition of Adolescent 11-21 years of age 40 million across the US 14% of the US population

Current Utilization of Healthcare Among Adolescents across the US (Summary of Studies) Methods Analyses of two national datasets MEPS (2002-2003) NAMCS/NHAMCS (2002) Assess utilization by Age, Gender, demographics Determine types of health providers seen

The critical role of primary care

Percent of Adolescents with a Usual Source of Care Summary from several studies

Receipt of Ambulatory Care* Within 1 Year Among Females *Ambulatory care- Any visit to a physician, nurse/nurse practitioner, physician assistant or midwife Christina Albertin et al. PAS Meetings, 2006

Receipt of Ambulatory Care* and Primary Care ** Within 1 Year *Ambulatory care- Any visit to a physician, nurse/nurse practitioner, physician assistant or midwife **Primary care- Any visit to a pediatrician, family physician, internist or general practitioner in an office-based practice or clinic.

Receipt of Ambulatory Care* and Primary Care ** Within 1 Year Most visits are to primary care *Ambulatory care- Any visit to a physician, nurse/nurse practitioner, physician assistant or midwife **Primary care- Any visit to a pediatrician, family physician, internist or general practitioner in an office-based practice or clinic.

Receipt of Ambulatory Care* and Primary Care ** Within 1 Year Most visits are to primary care Less so for older girls *Ambulatory care- Any visit to a physician, nurse/nurse practitioner, physician assistant or midwife **Primary care- Any visit to a pediatrician, family physician, internist or general practitioner in an office-based practice or clinic.

Receipt of Ambulatory Care and Primary Care Within 1 Year by Age Year and Gender *Ambulatory care- Any visit to a physician, nurse/nurse practitioner, physician assistant or midwife **Primary care- Any visit to a pediatrician, family physician, internist or general practitioner in an office-based practice or clinic.

Receipt of Ambulatory Care and Primary Care Within 1 Year by Age Year and Gender Younger boys: same as girls Older boys: use less care *Ambulatory care- Any visit to a physician, nurse/nurse practitioner, physician assistant or midwife **Primary care- Any visit to a pediatrician, family physician, internist or general practitioner in an office-based practice or clinic.

Types of Providers Seen % 11-13 yrs 14-16 yrs 17-21 yrs Cynthia Rand et al, Arch. Pediatrics and Adol Med. In press

Types of Providers Seen Pediatricians and Family MDs are critical OB-GYNs important % 11-13 yrs 14-16 yrs 17-21 yrs Cynthia Rand et al, Arch. Pediatrics and Adol Med. In press

Who is this person? Why is this important for adolescent immunizations?

Who is this person? Why is this important for adolescent immunizations? In attempting to diagnose a problem, first do the experiment that can confirm the most likely diagnosis

Who is this person? Why is this important for adolescent immunizations? Why do you rob banks?

Who is this person? Why is this important for adolescent immunizations? Because that’s where the money is Why do you rob banks?

Who is this person? Why is this important for adolescent immunizations? Willy Sutton (bank robber) Because that’s where the money is Why do you rob banks? Sutton’s Law: In attempting to diagnose a problem, first do the experiment that can confirm the most likely diagnosis

Critical Role of Primary Care Most adolescent visits are to primary care Major sources of healthcare: Young and middle teens: pediatricians & family MDs Older girls: add OB-GYNs Thus, focus adolescent immunizations towards: Primary care (pediatricians and family physicians) Younger adolescents

Critical Role of Primary Care Most adolescent visits are to primary care Major sources of healthcare: Young and middle teens: pediatricians & family MDs Older girls: add OB-GYNs Thus, focus adolescent immunizations towards: Primary care (pediatricians and family physicians) Younger adolescents Sutton’s Law

Outline Where should adolescents be vaccinated? Primary care Other settings What should change in primary care settings? What are the benefits of adolescent vaccination? We focus on two major research questions: We study methods to improve immunization delivery, particularly for poor children or those with chronic conditions. Second, we study implementation of new vaccines, using a “benches to trenches” approach. Studies include basic laboratory work to identify viruses, clinical investigation to measure disease burden, and health services research to study how best to deliver new vaccines.

Possible other settings Beyond Primary Care Medical Settings OB-GYN Emergency Departments (EDs) Subspecialty settings Schools- at school-based health centers Alternative sites: teen clinics, STD clinics, family planning and Title X clinics

No Ambulatory Care Within 1-Year Females Christina Albertin et al. PAS Meetings, 2006

Visit to ED Only Christina Albertin et al. PAS Meetings, 2006

Visits to Specialty Only Christina Albertin et al. PAS Meetings, 2006

Visit to School-based Clinic Only Christina Albertin et al. PAS Meetings, 2006

Visits to Ob/gyn Only Christina Albertin et al. PAS Meetings, 2006

Visits to Ob/gyn and Any Other Site (except 1° care) Christina Albertin et al. PAS Meetings, 2006

Any Primary Care Visit Christina Albertin et al. PAS Meetings, 2006

Overall Healthcare Utilization by Females within a 1-Year Period Christina Albertin et al. PAS Meetings, 2006

Overall Healthcare Utilization by Males within a 1-Year Period Christina Albertin et al. PAS Meetings, 2006

Possible other settings Beyond Primary Care Medical Settings OB-GYN Older girls! Emergency Departments (EDs) Small role Currently being studied (Stan Schaffer) Influenza vaccination? Less than 5% of adolescents seen in ED during 3-4 months High-risk adolescents If poor, and if no medical home– more likely to visit ED ED as usual source of care: 5% of all teens and 7% of minority teens Perhaps in some localities with poor primary care

Possible other settings Beyond Primary Care Medical Settings OB-GYN Older girls! Emergency Departments (EDs) Small role Currently being studied (Stan Schaffer) Influenza vaccination? Less than 5% of adolescents seen in ED during 3-4 months High-risk adolescents If poor, and if no medical home– more likely to visit ED ED as usual source of care: 5% of all teens and 7% of minority teens Perhaps in some localities with poor primary care

Possible other settings Beyond Primary Care Medical Settings OB-GYN Older girls! Emergency Departments (EDs) Small role Currently being studied (Stan Schaffer) Influenza vaccination? Less than 5% of adolescents seen in ED during 3-4 months High-risk adolescents If poor, and if no medical home– more likely to visit ED ED as usual source of care: 5% of all teens and 7% of minority teens Perhaps in some localities with poor primary care

Possible other settings Beyond Primary Care Medical Settings OB-GYN Older girls! Emergency Departments (EDs) Small role Currently being studied (Stan Schaffer) Influenza vaccination? Less than 5% of adolescents seen in ED during 3-4 months High-risk adolescents If poor, and if no medical home– more likely to visit ED ED as usual source of care: 5% of all teens and 7% of minority teens Perhaps in some localities with poor primary care

Possible other settings Beyond Primary Care Medical Settings OB-GYN Older girls! Emergency Departments (EDs) Small role Currently being studied (Stan Schaffer) Influenza vaccination? Less than 5% of adolescents seen in ED during 3-4 months High-risk adolescents If poor, and if no medical home– more likely to visit ED ED as usual source of care: 5% of all teens and 7% of minority teens Perhaps in some localities with poor primary care

Possible other settings Beyond Primary Care Medical Settings OB-GYN Older girls Emergency Departments (EDs) Small role Subspecialty settings ?no role Schools: at school-based health centers ?? Being studied Throughout the US, relatively few teens seen Large variations by community

Possible other settings Beyond Primary Care Medical Settings OB-GYN Older girls Emergency Departments (EDs) Small role Subspecialty settings ?No role

Possible other settings Beyond Primary Care Medical Settings OB-GYN Older girls Emergency Departments (EDs) Small role Subspecialty settings ?No role Schools: at school-based health centers ?? Being studied (Daley et al, Denver) Throughout the US, relatively few teens seen Large variations by community

Possible other settings Beyond Primary Care Medical Settings OB-GYN Older girls Emergency Departments (EDs) Small role Subspecialty settings ?No role Schools: at school-based health centers ?? Being studied Throughout the US, relatively few teens seen Large variations by community

Possible other settings Beyond Primary Care Medical Settings OB-GYN Older girls Emergency Departments (EDs) Small role Subspecialty settings ?No role Schools: at school-based health centers ?? Alternative sites: Some role Teen clinics, STD clinics, family planning and Title X clinics (Being studied- Stanley Schaffer) Extent of utilizations (National Survey of Family Growth): 15-17yr olds (11%) 18-19yr olds (14%) High-risk teens more

Outline Where should adolescents be vaccinated? Primary care Other settings What should change in primary care settings? What are the benefits of adolescent vaccination? We focus on two major research questions: We study methods to improve immunization delivery, particularly for poor children or those with chronic conditions. Second, we study implementation of new vaccines, using a “benches to trenches” approach. Studies include basic laboratory work to identify viruses, clinical investigation to measure disease burden, and health services research to study how best to deliver new vaccines.

No Visits to Medical Homes in Prior Year

No Visits to Medical Homes in Prior Year More likely if: Poor Uninsured Minority

No Visits to Medical Homes in Prior Year More likely if: Poor Uninsured Minority We need to: help get adolescents in for healthcare visits Patient reminders Improved access

Few Preventive Visits

Few Preventive Visits 1/3 - 2/3 of teens have a preventive visit within a year Most visits to primary care are NOT preventive visits

Few Preventive Visits 1/3 - 2/3 of teens have a preventive visit within a year Most visits to primary care are NOT preventive visits Medical Homes should: -Focus on  preventive visits -Vaccinate during other visits -Vaccinate while young (more preventive visits)

Medical homes will need to bring adolescents in for more visits

Special Case- HPV Vaccine 3 vaccinations Optimally at 0, 2 and 6 months But the “window” will be longer in the real world 12m, 18m, 24m Assume: most teens vaccinated in 1 care What are implications for visits to 1 care? Analysis of MEPS (2002-2003; n=2,900)

Special Case- HPV Vaccine 3 vaccinations Optimally at 0, 2 and 6 months But the “window” will be longer in the real world 12m, 18m, 24m Assume: most teens vaccinated in 1 care What are implications for visits to 1 care? Analysis of MEPS (2002-2003; n=2,900)

Special Case- HPV Vaccine # Added Visits Needed to Vaccinate Girls 11-12yr Cynthia Rand et al, Pediatrics. In press

Special Case- HPV Vaccine # Added Visits Needed to Vaccinate Girls 11-12yr If first vaccine at PREVENTIVE visit If first vaccine at ANY visit Cynthia Rand et al, Pediatrics. In press

Special Case- HPV Vaccine # Added Visits Needed to Vaccinate Girls 11-12yr If first vaccine at PREVENTIVE visit If first vaccine at ANY visit % # additional visits needed Cynthia Rand et al, Pediatrics. In press

Special Case- HPV Vaccine # Added Visits Needed to Vaccinate Girls 11-12yr If first vaccine at PREVENTIVE visit If first vaccine at ANY visit % # additional visits needed Cynthia Rand et al, Pediatrics. In press

Special Case- HPV Vaccine # Added Visits Needed to Vaccinate Girls 11-12yr If first vaccine at PREVENTIVE visit If first vaccine at ANY visit % # additional visits needed Cynthia Rand et al, Pediatrics. In press

Special Case- HPV Vaccine # Added Visits Needed to Vaccinate Girls 11-12yr If first vaccine at PREVENTIVE visit If first vaccine at ANY visit % # additional visits needed Cynthia Rand et al, Pediatrics. In press

Special Case- HPV Vaccine # Added Visits Needed to Vaccinate Girls 11-12yr If first vaccine at PREVENTIVE visit If first vaccine at ANY visit % % # additional visits needed # additional visits needed Cynthia Rand et al, Pediatrics. In press

Special Case- HPV Vaccine # Added Visits Needed to Vaccinate Girls 11-12yr If first vaccine at PREVENTIVE visit If first vaccine at ANY visit % % # additional visits needed # additional visits needed Most girls will need 2 or 3 additional visits Cynthia Rand et al, Pediatrics. In press

Special Case- HPV Vaccine # Added Visits Needed to Vaccinate Girls 11-12yr Medical Homes should: -Encourage preventive visits -Vaccinate at all office visits -Use tracking, reminder, recall

Who is this person? Why is this important for adolescent immunizations? W Edwards Deming Started the movement on Continuous Quality Improvement (CQI) 14 Principles for Improved Production

Who is this person? Why is this important for adolescent immunizations? W Edwards Deming Started the movement on Continuous Quality Improvement (CQI) 14 Principles for Improved Production Primary care practices must improve our operating processes to vaccinate adolescents

Outline Where should adolescents be vaccinated? Primary care Other settings What should change in primary care settings? What are the benefits of adolescent vaccination? We focus on two major research questions: We study methods to improve immunization delivery, particularly for poor children or those with chronic conditions. Second, we study implementation of new vaccines, using a “benches to trenches” approach. Studies include basic laboratory work to identify viruses, clinical investigation to measure disease burden, and health services research to study how best to deliver new vaccines.

Benefits to Adolescent Vaccinations Reduce vaccine preventable diseases HPV, Pertussis, Meningococcus, Hepatitis, Varicella, Tetanus, Influenza Reduce spread of infections (“herd immunity”) Might lead to improvements in other services Medical homes: Preventive services Macro level: Health insurance and systems for teens More coordinated care across healthcare settings Renewed focus on the adolescent population

Benefits to Adolescent Vaccinations Reduce vaccine preventable diseases HPV, Pertussis, Meningococcus, Hepatitis, Varicella, Tetanus, Influenza Reduce spread of infections (“herd immunity”) Might lead to improvements in other services Medical homes: Preventive services Macro level: Health insurance and systems for teens More coordinated care across healthcare settings Renewed focus on the adolescent population

Benefits to Adolescent Vaccinations Reduce vaccine preventable diseases HPV, Pertussis, Meningococcus, Hepatitis, Varicella, Tetanus, Influenza Reduce spread of infections (“herd immunity”) Might lead to improvements in other services Medical homes: Preventive services Macro level: Health insurance and systems for teens More coordinated care across healthcare settings Renewed focus on the adolescent population

Benefits to Adolescent Vaccinations Reduce vaccine preventable diseases HPV, Pertussis, Meningococcus, Hepatitis, Varicella, Tetanus, Influenza Reduce spread of infections (“herd immunity”) Might lead to improvements in other services Medical homes: Preventive services Macro level: Health insurance and systems for teens More coordinated care across healthcare settings Renewed focus on the adolescent population

Summary Lessons from Current Utilization Patterns Focus on primary care settings Pediatrics, Family MD, OB-GYN (for older girls) Consider “some” alternative settings (for subgroups) Schools, Teen-oriented settings, ? ED in some cases? Rethink strategies within medical homes More preventive visits, Vaccinate at all visits Tracking, reminder, recall Consider benefits of adolescent immunizations Vaccine preventable diseases Additional benefits to adolescent health care

Summary Lessons from Current Utilization Patterns Focus on primary care settings Pediatrics, Family MD, OB-GYN (for older girls) Consider “some” alternative settings (for subgroups) Schools, Teen-oriented settings, ? ED in some cases? Rethink strategies within medical homes More preventive visits, Vaccinate at all visits Tracking, reminder, recall Consider benefits of adolescent immunizations Vaccine preventable diseases Additional benefits to adolescent health care Sutton’s Law

Summary Lessons from Current Utilization Patterns Focus on primary care settings Pediatrics, Family MD, OB-GYN (for older girls) Consider “some” alternative settings (for subgroups) Schools, Teen-oriented settings, ? ED in some cases? Rethink strategies within medical homes More preventive visits, Vaccinate at all visits Tracking, reminder, recall Consider benefits of adolescent immunizations Vaccine preventable diseases Additional benefits to adolescent health care Sutton’s Law

Summary Lessons from Current Utilization Patterns Focus on primary care settings Pediatrics, Family MD, OB-GYN (for older girls) Consider “some” alternative settings (for subgroups) Schools, Teen-oriented settings, ? ED in some cases? Rethink strategies within medical homes More preventive visits, Vaccinate at all visits Tracking, reminder, recall Consider benefits of adolescent immunizations Vaccine preventable diseases Additional benefits to adolescent health care Sutton’s Law Quality -improvement

Summary Lessons from Current Utilization Patterns Focus on primary care settings Pediatrics, Family MD, OB-GYN (for older girls) Consider “some” alternative settings (for subgroups) Schools, Teen-oriented settings, ? ED in some cases? Rethink strategies within medical homes More preventive visits, Vaccinate at all visits Tracking, reminder, recall Consider benefits of adolescent immunizations Vaccine preventable diseases Spillover benefits to adolescent health care Sutton’s Law Quality -improvement

Who is this person? Why is this important for adolescent immunizations?

Who is this person? Why is this important for adolescent immunizations? Margaret Meade Anthropologist, studied societies and showed Importance of children Richness of diversity Need to understand lessons from history

Who is this person? Why is this important for adolescent immunizations? Never doubt that a small group of thoughtful, committed citizens can change the world; Indeed, it's the only thing that ever has.