1. Presented at The 129th Annual Meeting of the American Public Health Association Atlanta, GA, October 21–25, 2001 Presented by Amanda Honeycutt Abigail Shefer Linda McKibben Jeanne Krider Immunization Standing Orders Program Project: Costs and Cost- Effectiveness in LTCs P.O. Box 12194 · 3040 Cornwallis Road · Research Triangle Park, NC 27709 Phone: 770-234-5014 · Fax: 770-234-5030 · honeycutt@rti.org · www.rti.org

2. 2 Background on the Standing Orders Program (SOP) Project n CDC and CMS are collaborating to promote influenza and pneumococcal vaccines in LTCs through the use of SOPs l SOPs are policies that allow non-physician staff to vaccinate without direct physician involvement, such as a signed physician’s order n CMS peer review organizations (PROs) in 9 states are participating in the SOP project l PROs provide model programs and other resources to assist LTCs in adopting SOPs

3. 3 Study Objectives n To estimate the costs of implementing SOPs for immunization in LTCs n To estimate ongoing immunization program costs for LTCs with SOPs compared to those with other types of immunization programs n If SOPs are associated with higher vaccination rates relative to other immunization program types in LTCs l To evaluate the cost-effectiveness of SOPs by comparing differences in ongoing costs for LTCs with SOPs versus other immunization programs and differences in facility vaccination rates

4. 4 Previous Analyses--Effectiveness of SOPs n SOPs have been shown to be an effective means of raising immunization coverage rates for adults (see e.g., Klein and Adachi [1986] and Nichol [1991]) n The Guide to Community Preventive Services strongly recommends SOPs as a provider-based intervention for adults

5. 5 Previous Analyses--Costs of Provider-Based Interventions n Rosser et al. (1992) estimated that the costs of physician, telephone, and letter reminder programs were $0.43 to $6.05 per additional vaccine l Study assessed costs and outcomes for tetanus vaccines n For SOPs, no previous cost analyses or economic evaluations are available in the published literature

6. 6 Methods — Cost Data Collection n Visited 5 LTCs to observe the immunization process l identified key differences in the process for LTCs with SOPs compared to those with pre-printed admission orders, reminder/recall, or no immunization program n Data collection through self-administered questionnaires l Collected data on program start-up efforts and costs, staff and non-facility staff time required for the vaccination process, staff wage rates/salaries, and materials used l Mailed to 36 LTCs (4 in each of 9 INT states) l PROs requested participation during phone calls and mailed questionnaires to each LTC

7. 7 Methods — Effectiveness Data Collection n Surveys about facilities’ immunization policies and practices l Conducted by CDC l Mailed to all participating facilities in intervention states and a randomly selected sample of facilities in control states l Used to identify immunization program type for each LTC n Chart Data Abstraction l For up to 100 randomly selected residents in LTCs in both intervention and control states l Used to determine vaccination coverage rates for each facility for influenza and pneumococcal

8. 8 Methods — Data Analysis (I) n Cost estimation l Ongoing costs estimated from the LTC and societal perspectives u Per-resident cost estimates were generated for the following components: –Reminder program –Eligibility determination –Follow-up with MDs to obtain order –Vaccine administration, and –Tracking receipt of the vaccine

9. 9 Methods — Data Analysis (II) n Cost estimation l Mean estimated costs calculated for 5 different program types: u SOPs, u Preprinted admission orders (PPAO), u Reminder/recall (RR), u Advanced physician orders (APO), and u Usual care (no organized program) n Estimation of program effectiveness l Mean and median estimated immunization coverage rates calculated for each program type

10. 10 Results — Flowchart Analysis of Immunization Program Activities Typical Activities under a Standing Orders Program

11. 11 Results — Differences in LTC Immunization Activities by Program Type Typical Standing Orders Program Typical Reminder/Recall Program

12. 12 Results — Response Rates for Cost Questionnaire n 19 of the 36 questionnaires were returned with complete responses l Response rate of 53% n Reasons for the low response rate l Short time to complete the questionnaire--LTCs in 3 of the states were given about 1 month to complete l No incentives were provided to respondents l Cost data collection occurred at the same time as other intensive data collections (e.g., surveys, resident chart abstractions) in each facility l Many of the LTCs experienced turnover in key staff (e.g., Directors of Nursing)

13. 13 Results — Cost Estimates n Ongoing costs of SOPs v. alternative immunization programs

14. 14 Results — Estimated Influenza Immunization Program Rates n Flu vaccination coverage rates for SOPs v. alternative immunization programs

15. 15 Interpreting Results Accept SOP over PPAO, RR, and APO MoreSameLess More Same Less Incremental Effectiveness of SOP compared to alternative interventions Incremental Cost of SOP compared to alternative interventions Strong dominance for acceptance/rejection Weak dominance for acceptance/rejection No obvious decision without further analysis

16. 16 Cautionary note about interpreting results n More analyses are needed to determine whether facilities with SOPs have statistically significantly higher vaccination coverage rates l Assessment of the mean differences in effectiveness for the full sample of facilities l Multiple regression analysis to control for other factors that may be associated with immunization coverage rates, such as u Facility size u Ownership (chain/no-chain) u For-profit v. not-for-profit

17. 17 Study Limitations n Small sample size l Only 18 LTCs returned cost questionnaires for influenza immunization programs u However, good representation in terms of immunization program type and facility size n Outcomes considered are “intermediate” as opposed to final outcomes, such as the number of cases of influenza-related hospitalizations and deaths n Effectiveness estimates are not statistically significant for the small sample that participated in cost analyses

18. 18 Summary and Conclusions n Findings suggest that SOPs strongly dominate alternative immunization programs for influenza in LTCs in terms of their cost and vaccination coverage rates n Findings indicate that SOPs can lead to savings of $79 per additional vaccine recorded as compared to PPAOs and $98 per additional vaccine recorded as compared to RRs n Additional analyses of the relationship between immunization program type and coverage rates are needed (and planned) to determine whether these findings are representative