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Cost-Effectiveness of Pneumococcal and Influenza Vaccination Standing Order Programs
Chyongchiou Jeng Lin, PhD; Richard K. Zimmerman, MD, MPH; and Kenneth J. Smith, MD, MPH

Cost-Effectiveness of Pneumococcal and Influenza Vaccination Standing Order Programs

Chyongchiou Jeng Lin, PhD; Richard K. Zimmerman, MD, MPH; and Kenneth J. Smith, MD, MPH
Improving influenza and pneumococcal vaccination rates through outpatient standing order programs, which allow vaccination without physician orders, is economically favorable in older Americans.
However, only 42% of primary care physicians who immunized adults in their practices reported consistent use of SOPs.45 Factors associated with consistent use of SOPs include awareness about CDC/CMS stance on standing-order policies, physician perception about the power of SOPs, staffing levels (ie, number of assistants to help each clinician), and use of electronic medical records (EMRs).45,46 Record keeping and tracing of vaccination status is facilitated by the EMR. In some settings, the EMR can send alerts, make ordering and billing of vaccinations easy, or pull the most recent vaccination status into nursing, thereby facilitating the use of SOP protocols by nursing personnel.46 CMS has incentives for EMR usage which may further facilitate SOPs.

Given that the SOPs are effective in raising vaccination rates and economically reasonable, why are they not used more? Physicians and practice managers may be unaware of the economics of SOPs, which we estimate will cost less than $5 per person per year to implement; in contrast, the administration fee by Medicare for influenza and pneumococcal vaccines is about $21, depending on the locale.47 Several benefits can occur through SOP use, including reduced office visits for respiratory infections, decreasing both patient illness burden and strains on office manpower and flow during the influenza season. Another benefit is that adult immunization is a quality measure that can lead to bonus payments48 in some settings. The balance between SOP cost and the reimbursement that can occur through its use appears sufficient to justify SOPs.

Another possible reason for limited SOP use is unfamiliarity with resources. Peer-reviewed SOP tool kits, suggested related resources, and protocols are available at www.immunizationed.org49 and protocols for SOPs for various vaccines areavailable at www.immunize.org/standingorders.

Strengths and Limitations

Although inpatient SOP costs have been published for PPSV,15 to our knowledge, this is the first paper examining the cost-effectiveness of outpatient SOPs for both PPSV and influenza vaccination. The results of our study should facilitate planning by healthcare providers and administrators, office managers, insurers, and government officials.

Limitations include a number of estimated variables, as well as SOP cost and cost-effectiveness estimates that may not remain stable during these times of substantial change in healthcare. In addition, certain parameters, such as vaccine effectiveness estimates, are controversial.25,32,50-53 For these reasons, we varied all parameters in sensitivity analyses, finding in particular that PPSV effectiveness values had little influence on model results. Models based on national data provide estimates but do not necessarily reflect the costs in a particular locale. We assume that yearly SOP costs, and the improved vaccination rates that occur through their use, remain constant; thus our analysis will not be correct if SOP costs or effects change significantly over time. Finally, although a new vaccine, the pneumococcal conjugate vaccine, is now licensed in the United States,54 the ACIP has thus far declined to make recommendations for its routine use in adults; for this reason we have not considered it in our analysis.

With these limitations in mind, we conclude that SOP implementation for both PPSV and influenza vaccination in outpatient settings, targeting patients 65 years and older, is a promising and economically favorable investment, with costeffectiveness analysis results remaining robust to parameter variation over clinically plausible ranges.

Author Affiliations: From Department of Family Medicine (CJL, RKZ), Department of Internal Medicine (KJS), University of Pittsburgh School of Medicine, Pittsburgh, PA.


Funding Source: This study was supported by the Centers for Disease Control and Prevention (CDC) through Association for Prevention Teaching and Research Grant No TS-1432 and by the National Institute of Allergy and Infectious Diseases (R01AI076256). Its contents are the responsibility of the authors and do not necessarily reflect the official views of the CDC or the Association for Prevention Teaching and Research.


Author Disclosures: Drs Lin and Zimmerman report receiving consultancies from MedImmune and grants from MedImmune, Merck, and sanofiaventis. Dr Smith reports no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.


Authorship Information: Concept and design (CJL, RKZ, KJS); acquisition of data (CJL); analysis and interpretation of data (CJL, KJS); drafting of the manuscript (KJS); critical revision of the manuscript for important intellectual content (CJL, RKZ, KJS); statistical analysis (CJL, KJS); obtaining funding (RKZ); and supervision (KJS).


Address correspondence to: Chyongchiou Jeng Lin, PhD, Department of Family Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. E-mail: cjlin@pitt.edu.
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