1. Children’s Outcomes Research Program The Children’s Hospital Aurora, CO Children’s Outcomes Research Program The Children’s Hospital Aurora, CO Colorado Health Outcomes Program U. Colorado Denver Aurora, CO Adolescent Immunization Delivery in School-Based Health Centers: a National Survey March 30, 2009 43 rd National Immunization Conference Matthew F. Daley, MD Associate Professor, Pediatrics University of Colorado Denver

2. Disclosures The authors have no relevant financial relationships with any commercial interests to disclose No reference will be made to the use of medications in manners not licensed by the Food and Drug Administration

3. Background  Adolescents a targeted age group for many newer (Tdap, MCV4, HPV) and long-standing (influenza, varicella) vaccines  Many barriers to vaccination for adolescents  Strategies to strengthen adolescent immunization delivery system Reduce barriers in traditional medical home Explore immunization outside of traditional settings Ref: NVAC, Am J Prev Med, 2008

4. Vaccination in Schools  Many potential advantages, but numerous barriers as well  <15% U.S. schools currently provide vaccines  Schools with school-based health centers (SBHCs) may have resources and expertise to implement adolescent vaccination programs Ref: Lindley MC et al, Pediatrics, 2008

5. School-Based Health Centers  Staffed by physicians, nurse practitioners, physician assistants  Intended to provide comprehensive health care to students (i.e. serve as medical home)  ~2000 SBHCs nationally, increasing each year  Little known about immunization delivery in SBHCs Ref: Pastore DR et al, J Adolesc Health, 2001

6. Study Objectives Primary: to determine current immunization practices of SBHCs nationally: Vaccines offered Methods for improving immunization rates Mechanisms for vaccine financing Perceived barriers to adolescent vaccination Secondary: to examine reported experiences of SBHCs regarding HPV vaccination (unique)

7. Methods  Survey period: November 2007-March 2008  1000 SBHCs randomly sampled from National Assembly on School-Based Health Care listing  Exclusion criteria: Only provided dental or mental health services Did not see any patients 11-18 years old  Surveyed by internet and standard mail, with multiple mailings per subject

8. Results: Survey Response  185 of 1000 (19%) ineligible for survey  Among eligible SBHCs, 64% response rate  Survey response rates higher from Northeast (71%) and West (70%) than South (62%) and Midwest (49%)  Response rates also higher from rural (71%) and urban non-inner-city (68%) than urban inner-city (59%)

9. Characteristics of Responding SBHCs Number of students using SBHC at least once during school year <250 250-499 500-999 1000 or more 15% 40% 26% 19% Grades served by SBHCGrades 6-8 Grades 9-12 67% 71% Percent of students eligible for free/reduced lunch < 40% 40-59% 60-79% 80% or more 16% 21% 22% 42% Percent of SBHC users from minority racial/ethnic groups < 50% 50% or more 35% 65%

10. Administering Vaccines to Adolescents

11. Vaccines Offered at SBHCs 50%0%100% Recommended at 11-12 y.o. “Catch-up” High-risk groups (after 2008, influenza recommended for all)

12. Reported Methods Used to Improve Immunization Rates Method % Use immunization information system (registry) Registry accessible by PCPs in community Notify PCPs of vaccines given (letter, fax) Assessed UTD rates in preceding 2 years 69 59 50 61

13. Reported Methods for Reminder/Recall Reminder/recall method % Contacted adolescents directly at school Telephoned adolescents’ homes Sent mail home Email to parents Email to adolescents 60 54 3 2 Not mutually exclusive; 83% reported using one or more above methods

14. Consent and Vaccine Information Statements (VISs)  Multiple methods for obtaining parental consent: Consent sent home with student (76%) Consent at school registration (44%)  VISs also used multiple ways: Sent home with students prior to vaccination (62%) Sent home with students after vaccination (43%) Mailed to parents before vaccination (26%) Given out at school registration (14%)  19% of vaccinating SBHCs reported providing VISs after but not before vaccination (non-compliant with recs)

15. Vaccine Financing Among Vaccinating SBHCs  93% participated in VFC program  Vaccination practices by insurance: Reported vaccinating patients with Medicaid: 96% SCHIP: 91% Uninsured: 98% Private health insurance: 83%  Only 39% reported billing private health insurance for vaccines given

16. SBHCs That Currently Vaccinate: Perceived Barriers to Vaccination

17. Non-Vaccinating SBHCs: Perceived Barriers to Vaccination

18. Factors Associated with Providing Vaccinations  SBHCs with higher proportion of students eligible for free/reduced lunch more likely to provide vaccines (significant in univariate analyses only)  Increased odds of providing vaccines (multivariate): Lower proportion of students with outside PCP Serving grades 6-8 Region of country (Northeast more likely to vaccinate than other regions)  Not associated: urban/rural location, school size, type of state vaccine financing (VFC only, enhanced VFC, universal)

19. HPV Vaccination in SBHCs  Reported attitude of school administration to offering HPV vaccine: Moderate/definite resistance: 3% Mild resistance: 3% No resistance: 66% Had not discussed with school administration: 27%  SBHCs that provided gynecologic exams and Pap smears on site more likely to offer HPV vaccine  Most frequently reported barrier to providing HPV vaccine: not being able to vaccinate students who did not qualify for VFC program

20. Limitations  Not all SBHCs in the nation may be listed in NASBHC master listing  While survey response rate comparable to other national surveys, response rates varied by region and urban/rural location  Survey results represent reported practice; actual practice not observed

21. Summary of Findings  Vaccination practices 84% of SBHCs reporting vaccinating adolescents Most offered Tdap, MCV4, HPV vaccines  Methods to improve immunization delivery Many used immunization information system Most conducted some form of reminder/recall Most also assessed UTD rates

22. Additional Findings  Vaccine financing >90% participated in VFC, vaccinated publicly insured and uninsured students Most did not bill private insurance for vaccines Difficulty billing private insurance frequently cited as barrier, especially among SBHCs that do not currently vaccinate  HPV vaccination Little resistance from school administration to offering HPV vaccine in SBHCs Most frequently cited barrier: inability to vaccinate students who did not qualify for VFC program

23. Implications  SBHCs appear to be fully engaged in vaccine delivery to adolescents Early adoption of new vaccine recommendations More likely to use reminder/recall than private practices  SBHCs concentrated in “pockets of need” Students less likely to have PCP elsewhere Higher risk for missing needed immunizations

24. Scope of SBHCs  ~ 97,000 public elementary and secondary schools in U.S.  ~ 2,000 SBHCs operating in U.S.  Many barriers, financial and other, to expansion of SBHCs  Because of limited numbers, should be viewed as a complementary site (traditional sites are primary)  A “safety-net” for adolescents without reliable access to vaccines elsewhere

25. Relevance to Schools Without SBHCs  Caveat: SBHCs have infrastructure, resources, providers not available in schools without SBHCs  Several challenges to school-based vaccination highlighted Parental communication: for example, difficulty ensuring that parents receive VIS forms prior to vaccination Billing private insurance represents substantial barrier

26. Acknowledgments University of Colorado Denver  Allison Kempe, MD, MPH  Lori A. Crane, PhD, MPH  Jennifer Pyrzanowski, BA  Jennifer Barrow, MSPH  Katie Benton, MSPH Denver Health and Hospitals  Paul Melinkovich, MD  Steven Federico, MD  Lisa Abrams, MS, PNP National Assembly on School-Based Health Care  Linda Juszczak, DNSc, MPH, CPNP Centers for Disease Control and Prevention  C. Robinette Curtis, MD, MPH This investigation was funded by the CDC

27. Additional Slides

28. Univariate Analyses: Providing Vaccines and Free/Reduced Lunch % students eligible for free/reduced lunch % that vaccinate Unadjusted OR (95% CI) 0-39%76Ref. 40-59%831.51 (0.73, 3.10) 60-79%781.13 (0.57, 2.24) 80% or more922.60 (1.33, 5.09) This factor not significant in multivariate analyses

29. Multivariate Analyses: Factors Associated with Providing Vaccines AOR (95% CI) Reported % of students with outside PCP 0-24% 25-49% 50-74% 75% or more Ref. 1.26 (0.54, 2.92) 0.74 (0.36, 1.54) 0.31 (0.15, 0.62) Serves Grades 6-8No Yes Ref. 1.75 (1.04, 2.95) Tested but not significant in multivariate analyses: urban vs. rural school location; school size; type of state vaccine financing; percent of students eligible for free/reduced lunch Controlling for region of country

30. Perceived Barriers to Vaccinating Adolescents Definitely a barrier Among Vaccinating SBHCs Among Non- vaccinating SBHCs P-value Difficulty obtaining vaccination record 1880.03 Other health issues taking priority 419<0.001 Unable to vaccinate non- VFC students 17250.08 Difficulty billing private insurance 1741<0.001