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  • Improving Adult VaccinationProtecting our Most Vulnerable

    Dale W. Bratzler, DO, MPHPrincipal Clinical Coordinator

  • Do the vaccines work?

    Myth: Vaccines dont work in hospitalized patients.

  • 3

    Missed Opportunities

    Influenza vaccine is immunogenic in hospitalized patients and patients with chronic renal failure

    Pneumococcal vaccine approximately 50-75% effective preventing invasive disease

    Berry BB et al. Vaccine. 2001;19:3493-3498.

    Brydak LB et al. Vaccine. 2000;18:3280-3286.

    Christenson B, et al. Lancet. 2001;357:1008-1011.

    Nichol KL, et al. Arch Intern Med. 1999;159:2437-2442.

    Nichol KL. Vaccine. 1991;17(suppl 1):S91-S93.

  • 4

    Influenza VaccinationReductions in Hospitalization and Death

    2 yr study of elderly members of 3 HMOs- 1998-99 & 1999-00 seasons with > 140,000 persons in each years cohort

    Nichol KL, et al. N Engl J Med. 2003;348:1322-1332.

    19% 16%32%

    48%23%

  • 5 Benefits of Pneumococcal Vaccinations

    Group Effectiveness / Cost Savings

    All Elderly Persons 1

    Bacteremias 75% (57% to 85%)Cost savings $8.27 per person

    Elderly w/ Chronic Lung Disease 2

    Hospitalizations for pneumonia 43% (16% to 62%)

    Deaths 29% (9% to 44%)Cost savings $294 per person

    1 Sisk J. JAMA 1997; 278: 1333.2 Nichol KL. Arch Intern Med 1999; 159: 2437.

  • 6 Effectiveness of Pneumococcal Vaccination in Older Adults:The VSD Cohort Study

    3 year cohort study of 47,365 members of Group Health Coop (Seattle)

    PPV was associated with lower rates of bacteremia: HR 0.56 (95% CI 0.33 0.93)

    PPV was not associated with lower rates of community acquired pneumonia HR 1.07 (95% CI 0.99 1.14)

    HR = hazard ratio. Jackson LA, et al. NEJM 2003; 348: 1747.

  • 7

    Do the vaccines work??

    All agree, we need more effective vaccines

    Influenza vaccines that can be produced more rapidly after identification of a viral strain

  • What about immunosuppressed patients?

    Myth: We shouldnt vaccinate immunosuppressed patients.

  • 9

    Missed Opportunities

    Immunocompromised persons PPV

    HIV, leukemia, lymphoma, Hodgkins ds, multiple myeloma, malignancy, those receiving immunosuppressive chemotherapy, and those who have received an organ or bone marrow transplant

    Influenza Immunosuppression caused by medications or

    by HIVCDC. MMWR. 1997;46(RR-8):1-24.

    CDC. MMWR. 2003;52(RR-8):1-36.

  • Is Vaccination Safe?

    Myth: Vaccination is not safe for patients in the hospital. (vaccination

    can make me sick)

  • 11 Missed OpportunitiesMyth: Hospital Vaccination is Not Safe

    Many hospital and emergency department-based vaccination programs have been safely and effectively implemented with no evidence of significant risk

    Klein RS, et al. Arch Intern Med. 1983;143:1878-1881. (hospital pneumococcal vaccine)

    Magnussen CR, et al. Arch Intern Med. 1984;144:1755-1757. (hospital and ambulatory pneumococcal vaccine)

    Bloom HG, et al. J Am Geriat Soc. 1988;36:897-901. (hospital influenza and pneumococcal vaccines)

    Crouse BJ, et al. J Fam Pract. 1994;38:258-261. (hospital-based influenza vaccination)

    Nichol KL, et al. Am J Med. 1998;105:385-392. (10-year experience with inpatient influenza and pneumococcal vaccination)

    Rodriquez RM, et al. Ann Emerg Med. 1993;22:1729-1732. (ER-based influenza and pneumococcal vaccination)

    Slobodkin D, et al. Vaccine. 1998;16:1795-1802. (Inner-city ER-based influenza and pneumococcal vaccination)

  • 12 Missed OpportunitiesVaccine Side Effects

    Post-injection Symptoms in Elderly Receiving Influenza Vaccine.*Vaccine (%) Placebo (%) P value

    Fever 5.7 4.2 0.66

    Cough 6.6 5.1 0.62

    Fatigue 8.0 7.7 0.82

    Malaise 7.2 6.3 0.83

    Myalgia 4.8 4.2 0.84

    Sore arm 20.1 4.9

  • 13 Missed OpportunitiesVaccine Side Effects

    Systemic Symptoms Experienced Before and After Pneumococcal Vaccination.*

    Pre-vaccination (%) Post-vaccination (%) P valueFever 2.6 1.9 0.37Rash 4.8 0.7

  • 14 Vaccination Reality in the USThe Why..

    Despite the fact that influenza and pneumococcal vaccines are: clinically effective

    cost effective

    safe, and

    free to most elderly patients

    They are under-utilized!

  • Why should we vaccinate hospitalized patients?

  • 16 Rationale for Hospital-based Influenza Vaccination

    Age Group

    YPopulation

    N

    Discharged during the flu

    seasonN (%)

    Subsequent P&I hospitalizations*

    %

    Subsequent P&I deaths*

    %

    25-44 297,540 8,046 (3) 11 65

    45-64 198,120 6,439 (3) 32 82

    65-74 74,664 4,811 (6) 39 62

    > 75 44,138 5,188 (12) 45 66*Proportion of the population with subsequent hospitalization or death from pneumonia or influenza who had been discharged from a hospital.

    Fedson DS, Houck P, Bratzler D. [Editorial] Infect Control Hosp Epidemiol. 2000;21:692-699.

  • 17 Missed OpportunitiesBackground

    Fedson DS, et al. Infect Control Hosp Epidemiol. 2000;21:692-699.

  • 18

    Why give them in the hospital?

    Failure to vaccinate hospitalized patients is a missed opportunity Hospitalized patients may be at

    particularly risk of subsequent complications of influenza and pneumococcal disease

  • 19 Is Hospital-based Vaccination the Standard of Care?

    CMS and JCAHO have adopted influenza and pneumococcal vaccination of inpatients as measures of hospital quality

    PPV written into the MMA as a publicly reported measure of quality

    Hospital Compare Recommended by ACIP, IDSA, and

    others

  • 20 PN-2: Pneumococcal Vaccination

    Numerator Patients with pneumonia, age 65 and older, who

    were screened for pneumococcal vaccine status and were vaccinated prior to discharge, if indicated

    Denominator Pneumonia patients 65 years of age and older

    Key Exclusions Transfers from another acute care facility, no

    working diagnosis of pneumonia on admission, patients receiving comfort care only, expired in hospital, left AMA, discharged to hospice care, transferred to another hospital

  • 21

    PN-7: Influenza Vaccination Numerator

    Patients discharged during October through February with pneumonia, age 50 and over, who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated

    Denominator Pneumonia patients 50 years and older

    Key Exclusions Transfers from another acute care facility, no working

    diagnosis of pneumonia on admission, patients receiving comfort care only, expired in hospital, left AMA, discharged to hospice care, diagnosis of influenza, transferred to another acute care hospital

  • 22

    Additional Measure Notes

    We exclude patients who have had a bone marrow transplantation within the past year and patients actively receiving chemotherapy or radiation therapy

    Influenza vaccine not available this variable is only allowed when there is a national shortage of vaccine

  • 23 ResultsInfluenza

    Take home still no documentation in 61% of patients!

    0

    5

    10

    15

    20

    25

    30

    35

    40

    45

    10/2000-02/2001 01/2002-02/2002 10/2002-02/2003 10/2003-02/2004

    Perc

    ent

    Vaccinated Prior to Arrival Contraindicated Refused

    Proportion of Medicare patients discharged with a discharge diagnosis of pneumonia that were screened for or vaccinated prior to discharge.

  • 24 ResultsPneumococcal

    Take home still no documentation in 58.8% of patients!

    0

    5

    10

    15

    20

    25

    30

    35

    40

    45

    07/2000-03/2001 01/2002-12/2002 01/2003-12/2003 01/2004-06/2004

    Perc

    ent

    Vaccinated Prior to Arrival Contraindicated Refused

    Proportion of Medicare patients discharged with a discharge diagnosis of pneumonia that were screened for or vaccinated prior to discharge.

  • 25

    Where are we at now?

    Targeted efforts to measure performance and promote quality improvement on hospital-based vaccination have resulted in improved documentation of patient vaccination status

  • 26

    Where are we at now?

    .However Overall rates of inpatient vaccination

    have only marginally improved

    There is no information on vaccination status for more than half of the Medicare patients discharged from the hospital

  • 27

    Where are we at now?

    Refusals and contraindications accounted for a small proportion of the improvement in vaccination/screening documentation in Medicare patients

  • 28

    Wheres the greater risk of liability??

  • 29

    Where is the liability risk?

    Liability cases in three states Very consistent theme

    Young males who have previously had a splenectomy (no documentation of PPV)

    Subsequently hospitalized (in some, multiple times) not given PPV

    At least one case had visits to primary care physicians and an emergency department not given PPV

    All three developed purpura fulminans (two with significant amputations, one with menigitis and renal failure, one death)

  • 30

    Amsden said the jury's verdict would send a message to the hospital that it is focusing on the wrong areas for cost savings. Jordan's last day at the hospital

    cost $18,000 - the vaccine would have cost $25.

  • 31 PneumoniaCurrent Surveillance

    Take home High rates are achievable!

    83.4

    93

    0

    20

    40

    60

    80

    100

    Influen

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