1. 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.
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2. 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.

3. 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.

4. 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.

5. 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.

6. 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

7. 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”.

8. 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”.

9. 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.

10. 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