1. 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.

3. 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.

4. 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!

5. 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)

6. 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

7. 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

8. 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

10. District of Columbia
Intervention States
Control States

11. 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

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

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

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

15. Barriers to Immunizing Residents
N = 249 LTCs, Long Survey

16. Barriers to Implementing Standing Order Programs

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

18. 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

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

20. 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

21. 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

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

23. 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

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

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

26. 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