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Top Ten Reasons You Are Critical to

Improving Adult Immunization Rates

Laura Lee Hall, PhD Director, Center for Quality

ACP 2016 LA Chapter Meeting

March, 2016

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Acknowledgments

Support for adult immunization programs have been provided by the U. S. Centers for Disease Control and Prevention, Pfizer, Merck, and Sanofi. Thanks to ACP staff Rebecca Gehring and Selam Wubu - and project partners Bloomberg School of Public Health, Johns Hopkins University, and CECity, LSU, and the LA ACP Chapter!

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Top Ten Reasons You Are Critical to Improving Adult Immunization Rates

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Reason Number 10

1. Your patients will be protected. 2. Your voice is key. 3. Its fun working with your ACP colleagues. 4. It makes ($s and) sense. 5. ACP tools have been shown to be effective. 6. ACP has tools to support you. 7. ACP can help you understand your rates. 8. Team-based strategies align with PCMH/N model. 9. Adult immunizations will protect your patients. 10. Adult immunization rates remain unacceptably low.

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So Low, So Little Change

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Adult Influenza Vaccination Coverage by Age, 2013-14 season, United States, 2014 NHIS

65

72

48

32

43

0 10 20 30 40 50 60 70 80 90

Influenza, 19 yrs, HCP

Influenza, 65 yrs

Influenza, 50-64 yrs

Influenza, 19-49 yrs

Influenza, 19 yrs

% Vaccinated

HP2020 Targets: 70% 19 years, 90% HCP 19 years BRFSS estimates for 2013-14: 42.2% (18+), 32.2% (18-49), 45.3% (50-64), 65.0% (65+)

HCP internet panel survey 2013-14: 75.2%

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Adult Vaccination Coverage, Selected Vaccines by Age and High-risk Status, United States

28 (+3.6)

61

20

0 10 20 30 40 50 60 70 80 90

Herpes Zoster (Shingles), 60 yrs

Pneumococcal, 65 yrs

Pneumococcal, HR 19-64yrs

% Vaccinated

HP2020 Targets: 60% PPV HR 19-64 years, 90% PPV 65 years, 30% Shingles

Data Source: 2014 NHIS

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What About 2014 Data?

Overall, increases in adult vaccination coverage are needed. Although modest gains occurred in Tdap vaccination coverage among adults aged 19 years and herpes zoster vaccination coverage among adults aged 60 years, coverage for other vaccines and risk groups did not improve, and racial/ethnic disparities persisted for routinely recommended adult vaccines. Williams WW, Lu P, OHalloran A, et al. Surveillance of Vaccination Coverage Among Adult Populations United States, 2014. MMWR Surveill Summ 2016;65:136. DOI: http://dx.doi.org/10.15585/mmwr.ss6501a1

http://dx.doi.org/10.15585/mmwr.ss6501a1

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Racial/Ethnic Vaccination Disparities

Vaccination Group % Vaccinated Whites

Disparity, Blacks

Disparity, Hispanics

Disparity, Asians

Pneumo. , HR 19-64 yrs 21 -1 -5 -7 Pneumo., 65 yrs 65 -15 -20 -17 Tdap, 19 yrs 24 -12 -11 -8 Tdap, 19-64 yrs 26 -13 -13 -11 Tdap, 65 yrs 16 -11 -9 -1 Herpes Zoster, 60 yrs 32 -20 -17 -16

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How About Louisiana: Pneumococcal, HR

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Influenza Vaccination Coverage Estimates by State

National Immunization Survey-Flu (NIS-Flu) and Behavioral Risk Factor Surveillance System (BRFSS), 2010-11 through 2014-15 influenza seasons

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LSU Adult Immunization Rates

Vaccinations Performance Rate Influenza Vaccination 24% Pneumonia Vaccination Status for Older Adults 46% High Risk Pneumococcal Vaccination 25% Herpes Zoster (Shingles) Vaccination 8% Tdap (Tetanus, Diphtheria, Acellular Pertussis) Vaccination 10%

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Reason Number 9

1. Your patients will be protected. 2. Your voice is key. 3. Its fun working with your ACP colleagues. 4. It makes ($s and) sense. 5. ACP tools have been shown to be effective. 6. ACP has tools to support you. 7. ACP can help you understand your rates. 8. Team-based strategies align with PCMH/N model. 9. Adult immunizations will protect your patients. 10. Adult immunization rates remain unacceptably low.

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Each year, on average, 5 percent to 20 percent of the U.S. population gets the flu, tens of thousands are hospitalized and thousands die from flu-related illness. This costs an estimated $10.4 billion a year in direct medical expenses and an additional $16.3 billion in lost earnings annually.

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Flu Shots Prevent Heart Attacks

Effective in preventing major cardiac events among persons with exiting cardiovascular disease1-4 Meta-analysis of case control studies: 3

Acute respiratory illness/ILI increases acute MI risk by 2-fold Influenza vaccination efficacy (VE) 29% (95% CI=9-44%) against

acute MI Meta-analysis of randomized studies of persons with existing CVD:4

influenza VE 36% (95% CI=14% to 52.8%) Pooled VE of 29% (95% CI 9% to 44%) in preventing AMI, on a par

with other AMI preventive measures for secondary prevention 36% efficacy of statins for secondary prevention anti-hypertensives 15%18% smoking cessation interventions 26%.4

1. CDC. Prevention and Control of Seasonal Influenza: Recommendations of the ACIP U.S., 2014-15 Influenza Season. MMWR 2014; 63(32); 691-697. 2. American College of Cardiology recommendations for secondary prevention of atherosclerotic cardiovascular disease.

3. Barnes M, et al. Acute myocardial infarction and influenza: a meta-analysis of casecontrol studies. Heart 2015;101:17381747. 4. Udell JA, et al. Association between influenza vaccination and cardiovascular outcomes in high-risk patients: a meta-analysis. JAMA 2013;310:171120.

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Burden of Shingles

Approximately 4 cases per 1,000 U.S. population annually; 10 in 1,000 among people 60 years +

About 1 million cases of zoster annually U.S. Produces rash over the course of 3-5 days; heals in 2-4 weeks Postherpetic neuralgia (PHN) is most common complication in up to 30%

of patients; last weeks to months; risk and severity of PHN increases in older adults

The pain associated with shingles and PHN is often described as burning, stabbing, itching, or aching. In one study, 42% of those surveyed described shingles pain as horrible and

excruciating. In fact, the severity of shingles pain can exceed musculoskeletal pain, osteoarthritis, chronic cancer pain, and childbirth.

1. CDC. Prevention of Herpes Zoster. MMWR 2008. 57(RR-5): 1-30. 2. CDC. Active Bacterial Core Surveillance. http://www.cdc.gov/abcs/reports-findings/survreports/spneu13.pdf 3. CDC. Notifiable Diseases and Mortality Tables. MMWR 2013. 61(51&52): ND-719 ND 732.

18 Drolet M, et al. The impact of herpes zoster and postherpetic neuralgia on health-related quality of life: a prospective study. CMAJ 2010.

Zoster and QoL

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Estimated Annual Incidence and Costs of Major VPD in U.S. Adults 50, 2013

Herpes Zoster,

937,773

Pertussis, 387,809 Pneumo-coccal , 603,337

Influenza, 8,101,104

Herpes Zoster,

5.0

Pertussis, 0.4

Pneumo-coccal,

5.1

Influenza, 16.0

Incidence (total estimated number of cases) Cost (in billions of dollars)

McLaughlin JM et al., Estimated Human and Economic Burden of Four Major Adult Vaccine-Preventable Diseases in the United States, 2013, J Primary Prevent (2015).

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Reason Number 8

1. Your patients will be protected. 2. Your voice is key. 3. Its fun working with your ACP colleagues. 4. It makes ($s and) sense. 5. ACP tools have been shown to be effective. 6. ACP has tools to support you. 7. ACP can help you understand your rates. 8. Immunizations part of PCMH model and required

performance measure 9. Leading public health achievement of 20th century 10. Adult immunization rates remain unacceptably low.

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PCMH and Preventive Care

A model that improves people's health and wellbeing by helping doctors proactively manage and coordinate care for their patients, increasing the use of preventive care and regular screenings, and supporting people with diabetes, depression, and other chronic diseases in new and innovative ways (PCMH CSI-RI)

A team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes, including the provision of preventive services; this care model promotes improved access and communication; care coordination and integration; and care quality and safety (ACP)

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NCQA Standards: Directly Relevant Must Pass Elements

Patient-centered Access Team-based Care Population Health Management - At least annually the

practice proactively identifies populations of patients and reminds them of needed care including: At least two different preventive care services; At least two different immunizations

Care Management and Support Care Coordination and Care Transitions Performance Measurement and Quality Improvement

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Post-SGR Medicare Payment Models under MACRA

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Immunizations and Reporting Programs

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Reason Number 7

1. Your patients will be protected. 2. Your voice is key. 3. Its fun working with your ACP colleagues. 4. It makes ($s and) sense. 5. ACP tools have been shown to be effective. 6. ACP has tools to support you. 7. ACP can help you understand your rates. 8. Team-based strategies align with PCMH/N model. 9. Leading public health achievement of 20th century 10. Adult immunization rates remain unacceptably low.

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Medconcert: Learning and Performance Monitoring Platform

Welcome Page

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Medconcert: Performance Monitoring Dashboard

View your performance based on vaccine measure and against established benchmarks and peer comparators.

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Medconcert: Patient Population Management/Outliers

View your patient population and your patient outliers to see where gaps may be.

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Medconcert: Improvement Tools

Access to improvement tools and educational resources for patients and staff.

Resources specific to each vaccine measure and focusing on the adult immunization practice standards.

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Medconcert: Community

A place to share information and learn from your peers, coaches, and ACP.

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Reason Number 6

1. Your patients will be protected. 2. Your voice is key. 3. Its fun working with your ACP colleagues. 4. It makes ($s and) sense. 5. ACP tools have been shown to be effective. 6. ACP has tools to support you. 7. ACP can help you understand your rates. 8. Team-based strategies align with PCMH/N model. 9. Leading public health achievement of 20th century 10. Adult immunization rates remain unacceptably low.

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Improvement Tools

Champion Training Practice Assessment Tool Practice Coaching Calls Webinars Focus on Topics Important to Practices (costs, team-

based approaches, referral tools, recommendation) PDSA Library

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Adult Immunization Residency QI Program Content

A Facilitator Guide to help with delivery of the module, including needed equipment, timing and instruction of the program, and active learning tools (see guide, modules, example QI projects, and resource list in folder) Module Presentations & Handouts in PowerPoint and Word format. A list of Example Quality Improvement Projects to facilitate

brainstorming of appropriate projects. A comprehensive Resource List containing patient education

materials, clinical guidelines, and provider tools. Program Evaluations to assess program impact.

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Adult Immunization and Quality Improvement for Residents Module 1 The Science of Adult Immunization

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Overview

Module 1 Science of Adult Immunization Adult immunization rates and recommended vaccine schedule Vaccination among special populations:

Diabetics Healthcare workers Pregnant women The elderly

Module 2 Quality Improvement in Adult Immunization

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Adult Immunization and Quality Improvement for Residents Module 2 Quality Improvement in Adult Immunization

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Overview

Module 1 Science of Adult Immunization Module 2 Quality Improvement in Adult

Immunization Standards for Adult Immunization Practice Strategies to Increase Adult Immunization What is Quality Improvement? Example QI Projects Additional Resources

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Reason Number 5

1. Your patients will be protected. 2. Your voice is key. 3. Its fun working with your ACP colleagues. 4. It makes ($s and) sense. 5. ACP tools have been shown to be effective. 6. ACP has tools to support you. 7. ACP can help you understand your rates. 8. Team-based strategies align with PCMH/N model. 9. Leading public health achievement of 20th century 10. Adult immunization rates remain unacceptably low.

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Results From CDC Funded Pilot

Baseline (%)

Follow-up (%)

Improvement

(%) Herpes Zoster (shingles) Vaccination 51.92 66.18 14.26 High Risk Pneumococcal Vaccination 69.13 92.65 23.52 Influenza Immunization 79.34 97.64 18.3 Influenza Vaccination Coverage Among Healthcare Personnel 75 100 25 Pneumococcal Vaccination Status for Older Adults 96.12 99.01 2.89 Tdap Vaccination 76.56 91.23 14.67

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Reason Number 4

1. Your patients will be protected. 2. Your voice is key. 3. Its fun working with your ACP colleagues. 4. It makes ($s and) sense. 5. ACP tools have been shown to be effective. 6. ACP has tools to support you. 7. ACP can help you understand your rates. 8. Team-based strategies align with PCMH/N model. 9. Leading public health achievement of 20th century 10. Adult immunization rates remain unacceptably low.

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Vaccines Profit Margin

Vaccine MCR Margin Non-MCR Margin

Estimated Net Profit 9/12-8/13

influenza 29.07 20.61 13,106.16

PPSV23 38.70 21.54 1,794.06

Tdap 49.05 30.45 11,985.90

Zostavax 20.54 123.24

HPV4 50.00 600.00

PCV13 35.52 14.89 50.41

Other Vax: 20.00 est 100.00

TOTAL: $27,759.77

Decision points: - Which vaccines

to stock - Storage and

handling - Purchasing

method - Optimal coding - Standing

orders/team-based care

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Do You Want to Test the Tool?

EMAIL ME: laurah@acponline.org

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Reason Number 3

1. Your voice is key. 2. Its fun working with your ACP colleagues. 3. Your voice is key!

4. It makes ($s and) sense. 5. ACP tools have been shown to be effective. 6. ACP has tools to support you. 7. ACP can help you understand your rates. 8. Team-based strategies align with PCMH/N model. 9. Leading public health achievement of 20th century 10. Adult immunization rates remain unacceptably low.

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Provider Recommendation Translates Into Higher Vaccination Rates Even greater among people of color

Nichol KL, et al. J Gen Intern Med. 1996;11(11):673-677.

27% 15.8%

82% 85.1%

0

20

40

60

80

100

Influenza PPV

No recommendation Recommendation

Vacc

inat

ion

Rate

(%)

(Even for Patients With Negative Attitudes)

*High-risk patients were those ages 65 and older or those having heart disease, lung disease, diabetes, or other serious illness.

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Who Most Influences Adults Decisions to Get Immunized?

All Adults

Personal physician 69%

Family member 19%

Celebrity physician, public figure, other 7%

None of the above 4%

No answer 1%

NFID. 2009 National Adult Immunization Consumer Survey: Fact Sheet. Available at: http://www.adultvaccination.com/doc/Survey_Fact_Sheet.pdf. Accessed June 15, 2011. AMA. American Medical News. Physicians asked to persuade adults to get immunized. Available at: http://www.ama-assn.org/amednews/2009/08/03/prsc0803.htm. Accessed June 13, 2011.

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ALMOST 90% !

48 Brown M, Sinsky C Family Practice Management March/April

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Reason Number 2

1. Your patients will be protected.Your voice is key. 2. The Public Health Needs Your VoiceIt makes ($s and) sense. 3. ACP tools have been shown to be effective. 4. ACP has tools to support you. 5. ACP can help you understand your rates. 6. Team-based strategies align with PCMH/N model. 7. Leading public health achievement of 20th century 8. Adult immunization rates remain unacceptably low.

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Published-1998 Retracted-2010

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Greg Poland MD Director Mayo Vaccine Research Group

A fog of suspicion cast upon all v

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THE COST OF A SCARE

53 VACCINE 28 (2010) 1709-16

Anti-vaccination Misinformation on the Internet: A Postmodern Pandoras Box

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Who The Public Perceives As Credible

MOST CREDIBLE Local citizens perceived as neutral, respected, informed about

the issue-clergy Nurses, physicians, firefighters Professors/educators (especially from respected local

institutions) Media Environmental/advocacy groups Federal government State/local government Industry For profit consultants LEAST CREDIBLE

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Speaker Training

Immunization Program Quality Connect

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Dr. House

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Reason Number 1

1. Value and Joy! 2. Your patients will be protected. 3. Your voice is key. 4. It makes ($s and) sense. 5. ACP tools have been shown to be effective. 6. ACP has tools to support you. 7. ACP can help you understand your rates. 8. Team-based strategies align with PCMH/N model. 9. Leading public health achievement of 20th century 10. Adult immunization rates remain unacceptably low.

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ACP Quality Connect Mission

To create and sustain a learning community of empowered physicians and other health care professionals, patients and caregivers, to improve health, care delivery and outcomes. Create QI network of internists and other physicians and their health care teams Partner with state chapters and health care systems Highlight patient engagement as part of health care team Add value and joy to clinicians in everyday practice

Value = MOC, VBP/APM, MU, revenue, efficiency (team-based care), professional development Joy = Reduced administrative burden, collaborating with colleagues and peers andtaking care of your patients!

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Join Your Colleagues to Raise the Rates!! THANKS!

Top Ten Reasons You Are Critical to Improving Adult Immunization RatesLaura Lee Hall, PhDDirector, Center for QualityACP2016 LA Chapter MeetingMarch, 2016AcknowledgmentsTop Ten Reasons You Are Critical to Improving Adult Immunization RatesReason Number 10So Low, So Little ChangeAdult Influenza Vaccination Coverage by Age, 2013-14 season, United States, 2014 NHISAdult Vaccination Coverage, Selected Vaccines by Age and High-risk Status, United StatesWhat About 2014 Data?Racial/Ethnic Vaccination DisparitiesHow About Louisiana: Pneumococcal, HRInfluenza Vaccination Coverage Estimates by State LSU Adult Immunization RatesReason Number 9Slide Number 14Slide Number 15Flu Shots Prevent Heart AttacksBurden of ShinglesZoster and QoLEstimated Annual Incidence and Costs of Major VPD in U.S. Adults 50, 2013Reason Number 8PCMH and Preventive CareNCQA Standards: Directly Relevant Must Pass ElementsPost-SGR Medicare Payment Models under MACRAImmunizations and Reporting ProgramsReason Number 7Medconcert: Learning and Performance Monitoring Platform Medconcert: Performance Monitoring DashboardMedconcert: Patient Population Management/OutliersMedconcert: Improvement ToolsMedconcert: CommunityReason Number 6Improvement ToolsAdult Immunization Residency QI Program ContentAdult Immunization and Quality Improvement for ResidentsModule 1 The Science of Adult ImmunizationOverviewAdult Immunization and Quality Improvement for ResidentsModule 2 Quality Improvement in Adult ImmunizationOverviewReason Number 5Results From CDC Funded PilotReason Number 4Vaccines Profit MarginSlide Number 42Do You Want to Test the Tool?Reason Number 3Slide Number 45Provider Recommendation Translates IntoHigher Vaccination Rates Even greater among people of colorWho Most Influences Adults Decisions to Get Immunized?Slide Number 48Reason Number 2Slide Number 50Slide Number 51Slide Number 52Anti-vaccination Misinformation on the Internet: A Postmodern Pandoras BoxWho The Public Perceives As CredibleSlide Number 55Slide Number 56Reason Number 1ACP Quality Connect MissionJoin Your Colleagues to Raise the Rates!!THANKS!Slide Number 60