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Supplements A Managed Care Perspective on the Importance of Optimizing Influenza Vaccinations in Older Adults
Influenza in Older Patients: A Call to Action and Recent Updates for Vaccinations
Miranda Wilhelm, PharmD
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Managed Care Considerations and Economic Implications of Vaccination Practices
Mary Patricia Nowalk, PhD, RD

Managed Care Considerations and Economic Implications of Vaccination Practices

Mary Patricia Nowalk, PhD, RD
One such intervention is the 4 Pillars Practice Transformation Program (also called the 4 Pillars Immunization Toolkit or 4 Pillars Program), a compilation of evidence-based best practices for increasing immunization rates in the primary care setting.17,18 This program addresses the Task Force’s 3 primary interventions and adds motivation by an immunization champion to form the 4 pillars. Strategies within each pillar are derived from decades of research into the barriers and facilitators of adult immunizations from the perspective of providers and patients, along with trials of successful strategies to increase immunization rates.17,19 The 4 Pillars Program allows primary care practices of all sizes and structures to customize the intervention to suit their unique, individual needs.

The intervention strategies used to increase adult vaccination are shown in Table 1, grouped by pillar and delineated specifically for influenza immunization.17

The 4 Pillars Program was tested for effectiveness in 25 primary care practices in Pittsburgh and Houston in a randomized, controlled cluster trial. The practices were randomized to intervention and control arms. A total of 70,549 adults was included, with baseline mean age of 55.1 years and a distribution that was 35% male, 21% nonwhite, and 35% Hispanic. After 1 year of follow-up, both the intervention and control cohorts significantly increased influenza vaccination, averaging increases of 2.7 to 6.5 percentage points. The likelihood of influenza vaccination was significantly higher in practices with lower percentages of patients with missed opportunities for immunization. In the second year intervention, the likelihood of vaccination again increased, especially in those sites that reduced missed opportunities for vaccination.17 The 4 Pillars Program has been successfully used to raise vaccine uptake for other adult and adolescent vaccines.19-21

The cost-effectiveness of the 4 Pillars Program for improving vaccination rates in older adults has also been studied. Smith et al assessed the program by estimating cost-effectiveness to increase pneumococcal, influenza, and pertussis-containing vaccine uptake in adults 65 years and older seen in the primary care setting. The study was based on QALYs, public health outcomes, costs, and vaccination rates; intervention costs were obtained from the randomized controlled clinical trial referenced above. By using the 4 Pillars Program and extrapolating data over 10 years, results showed that there would be approximately 60,920 fewer influenza cases, along with 2031 fewer pertussis cases and 13,842 fewer pneumococcal illnesses in the older population studied. The per-person vaccination and illness costs would be higher using the program intervention (an increase of $23.93) but would have an increase in effectiveness of $7635 per QALY gained with the intervention (Table 2).22 There was no individual parameter variation that caused the intervention to cost more than $50,000 per QALY gained.22

The Role of Standing Orders in Increasing Vaccination Rates

Among the strategies in the 4 Pillars Program, one of the most effective has been shown to be standing order programs (SOPs). SOPs allow clinicians to administer influenza and pneumonia vaccinations according to a protocol approved by a physician or health system without an individual physician order or examination. Assessments have shown that such programs may be both a promising and an economically favorable investment in flu prevention.23,24

Zimmerman et al assessed the awareness of SOPs in the primary care setting using a nationwide survey of 1640 primary care physicians. Among the 67% who responded, 42% reported consistent SOP use, although they differed in awareness and recommendations surrounding its use, size and type of practice, number and level of training of in-practice clinical staff, and other staff attributes. Variables associated with the highest likelihood of using SOPs for influenza vaccination were awareness of recommendations to use SOPs and physician agreement with their effectiveness for use in practice.25 In a related study using the same sample, Albert et al showed that only 23% of those surveyed used SOPs consistently for both influenza and pneumococcal vaccines, with only 20% using SOPs for influenza immunization. Critical practice-level factors that were associated with enhanced use of SOPs included perceived practice openness to change, a strong teamwork focus, EMR access, presence of an “immunization champion” within the practice to promote SOP use, and access to nurse/physician assistant staff as opposed to only medical assistants for SOP implementation. The investigators concluded that SOPs are underused overall but have the potential for substantial positive public health impact, and that more clinician and nonclinician education surrounding SOPs should be considered nationally, focusing on current vaccine recommendations and policies to better administer immunizations and facilitate adoption of SOPs.26

SOPs for influenza and pneumococcal vaccination among those 65 years or older have been shown to be cost-effective from a third-party payer perspective, costing $14,171 per QALY gained, compared with no SOP program. Lin et al used a Markov model and showed that SOPs are economically favorable in scenarios when SOPs increased vaccination rates by 4% or more and when costs to implement were less than $21 per person. Thus, SOPs have the potential to improve public health through increased immunization rates, and they allow physicians more time to address other health issues in the limited amount of time allotted per patient.24

A number of other evidence-based clinical strategies have been shown to increase adult vaccination rates and improve vaccine parity. These include enhanced documentation systems (eg, EMRs, health maintenance flow sheets in patient charts), routine screening of vaccination status, provider reminders, and recall systems.23 One best-practice model used by the US Veterans Health Administration included development of performance measures and accountability standards for rates of preventive services, including immunizations. Multiple systems-based interventions were used to improve vaccination coverage rates in both hospitals and clinics, including clinical reminders, feedback, annual distribution of an influenza vaccination toolkit, and national coordination of vaccine distribution. This led to improvements across all geographic regions, types of hospitals, and sociodemographic groups.27 Overall, health systems must establish better in-practice structures to track patient vaccination status, implement SOPs for appropriate vaccinations, and provide stronger and clearer recommendations to older adults to undergo influenza vaccination.23

An important factor in a practice’s ability to increase uptake is its readiness to implement changes necessary to improve adult vaccination. Using qualitative research techniques, including observation and key informant interviews, Hawk et al identified 4 practice characteristics that were important to implementation of the 4 Pillars Program. They were degree of quality improvement history, communication and practice leadership style, effectiveness of the immunization champion, and organizational flexibility. Practices that scored high overall on these factors (high implementers) also implemented the most strategies to improve vaccination rates, such as SOPs, and demonstrated significant increases in influenza and tetanus–diphtheria–pertussis vaccination uptake.28

Patients and Influenza Vaccination Acceptance

Vaccine hesitancy remains an intractable barrier to increasing adult influenza vaccination rates. Reasons given by patients for not receiving the influenza vaccine are frequently examined in the context of the theory of reasoned action and the theory of planned behavior. These behavioral theories divide barriers and facilitators of vaccination into knowledge and attitudes, social norms, and perceived behavioral control, with the addition of habit in revised iterations.29 Harris et al studied adults 18 years and older who were surveyed in November (mid-influenza vaccination season) about their intention to receive influenza vaccine and in March and April (after influenza vaccination season) about their actual vaccination behavior. Just over half of those who intended to receive influenza vaccine had received it by the end of the season. Of those who intended to receive the vaccine but failed to do so, 50% cited not getting around to being vaccinated as their primary reason. Twenty-two percent of those not intending to be vaccinated believed they did not need the vaccine. A strong recommendation from a healthcare provider would have improved receptivity to vaccination among 81% of those with intention and 44% of those without an intention.30 Reviews of quantitative and qualitative studies to identify the barriers to influenza vaccination uptake and intention found that the most frequently reported deterrents to vaccination acceptance were negative attitudes toward the vaccine, including worries about its safety and belief that the vaccine causes influenza, decreased perceived effectiveness of the vaccine, and a lack of trust in health authorities. Social norms, such as a perception that  influenza vaccination was not the norm among one’s peers, were also found to be a barrier to influenza vaccination.   However, physician recommendation was an important facilitator.31 In addition, low perceived risk of influenza and of the severity of disease are frequent barriers to vaccination. A 2015 study found that unvaccinated patients seeking outpatient medical care for an acute respiratory illness with intent to receive future vaccination were 1.5 times as likely to have actual laboratory-confirmed influenza when compared with those who were already vaccinated and intended another vaccination in the following season. Yet a significant number of patients reported no intention to receive the influenza vaccine in the next season, despite requiring medical treatment for an acute respiratory illness.32 Many unvaccinated adults report that they forgot to receive it, a measure of perceived behavioral control, while vaccine receipt has been highly associated with previous vaccination history.33


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