childhood immunizations: practice barriers and solutions...inter-changeability with emrs key reduce...
TRANSCRIPT
Childhood Immunizations: Practice Barriers
and Solutions September 18, 2013
Peter G. Szilagyi, MD, MPH Professor of Pediatrics
University of Rochester School of Medicine and Dentistry
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Agenda Item Time
Welcome and Introductions
Janet Gingold, MD, MPH
5 min
• Burden of childhood vaccine-
preventable disease
• Strategies to improve immunization
rates
• Challenges and methods to
overcome challenges
• Useful immunization resources
Peter G. Szilagyi, MD, MPH
45 min
Questions and Answers 10 min
Housekeeping
All phones are muted until Q&A at end
Type questions during the presentation into the chat
box and send to Janet Gingold or everyone or wait
to ask over phone during Q&A
3
Attendance Tracker for CME & MOC Within 1-2 days of the webinar, please submit a
spreadsheet containing the following information
about the webinar participants from your practice:
Please send this spreadsheet to Liz Rice-Conboy at
[email protected]. An evaluation survey will be
sent out via REDCap. Liz will email a PDF of the
CME Certificate directly to each participant.
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Full name
(as it will
appear on
your CME
Certificate)
Email address
(you will be sent
a webinar
evaluation after
the webinar)
Designation
(as it will
appear on
your CME
Certificate)
Full Address (only if
this differs from the
address of the
Project leader’s
address)
CME Designation The American Academy of Pediatrics (AAP) is accredited by the Accreditation Council for
Continuing Medical Education (ACCME) to provide continuing medical education for
physicians.
The AAP designates this live activity for a maximum of 1.00 AMA PRA Category 1
Credit(s)™. Physicians should claim only the credit commensurate with the extent of their
participation in the activity.
This activity is acceptable for a maximum of 1.00 AAP credits. These credits can be
applied toward the AAP CME/CPD Award available to Fellows and Candidate Members of
the American Academy of Pediatrics.
The American Academy of Physician Assistants (AAPA) accepts certificates of
participation for educational activities certified for AMA PRA Category 1 Credit™ from
organizations accredited by ACCME. Physician assistants may receive a maximum of
1.00 hours of Category 1 credit for completing this program.
This program is accredited for 1.00 NAPNAP CE contact hours of which 0.25 contain
pharmacology (Rx) content per the National Association of Pediatric Nurse Practitioners
(NAPNAP) Continuing Education Guidelines.
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Speaker’s background Peter Szilagyi is a Professor of Pediatrics at the University of
Rochester School of Medicine and Dentistry and division chief of the
Division of General Pediatrics at the University of Rochester. He
directs a large research operation in the Robert J Haggerty Health
Services Research Laboratory. His studies to improve the quality of
care and outcomes for vulnerable children have led to important
changes in immunization delivery, child health care financing and
care of children with chronic conditions. For example, in the field of
immunizations his studies have contributed to the Vaccines for
Children Program and the focus on the medical home for vaccine
delivery; in the field of healthcare financing his studies have
contributed to the formation and continuation of the SCHIP program.
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Locally, Dr. Szilagyi spends substantial time each week mentoring faculty and fellows,
directs the General Academic Pediatric Fellowship Program. He directs a city-wide
outreach program that has reduced disparities in immunizations, and is Chair of the
Board of Directors of the Monroe Plan, the largest Medicaid Managed Care and SCHIP
plan in Upstate NY which serves >200,000 members. In 2010 he was the first recipient of
the Dr. David Satcher Award for community health improvement, a Rochester-based
award.
Comparison of Immunization Quality
Improvement Dissemination Strategies (CIzQIDS)
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CME Disclosure
I have no relevant financial relationships with the
manufacturer(s) of any commercial product(s) and/or
provider of commercial services discussed in this CME
activity.
I do not intend to discuss an unapproved/investigative
use of a commercial product/device in my presentation.
Learning Objectives
After completing this course, you should be able to:
a) Understand the burden of childhood vaccine-
preventable disease
b) Identify strategies and methods to improving
immunization rates and confront practice system
barriers
c) Recognize useful immunization resources
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Recommended childhood
immunization schedule 2013
Recommended childhood
immunization schedule 2013
Vaccinations recommended to prevent 13 childhood diseases!
The next 3 slides are from Ann
Schuchat (CDC)
Assistant Surgeon General
Director, National Center for Immunization and
Respiratory Diseases
Texas Immunization Summit 2012 – Houston, Texas
September 27, 2012
State of the Nation is Strong
Most vaccine-preventable diseases at record lows
Achieved & sustained high childhood immunization
Reduced disparities in childhood coverage
Introduced multiple new vaccines
Improved influenza vaccine supply
From Ann
Schuchat
* Target is 80% for Rotavirus and 60% for Hepatitis A
† DTP/DTaP (3+) is not a Healthy People 2020 objective. DTaP (4) is used to assess Healthy People 2020 objectives.
§ Reflects 3+ doses through 2008, and Full Series (3 or 4 doses depending on type of vaccine received) 2009 and later
¶ 2 or 3 doses, depending on the type of rotavirus vaccine received
Note: Children in the USIS and NHIS were 24-35 months of age. Children in the NIS were 19-35 months of age.
Source: USIS (1967-1985), NHIS (1991-1993) CDC, NCHS and NCIRD, and NIS (1994-2011), CDC, NIP, NCHS and NCIRD; No data from 1986-1990 due to cancellation of USIS because of budget reductions.
Increasing Vaccine-Specific Coverage Rates Among Preschool-Aged Children: 1967 - 2011
0
20
40
60
80
100
1967 1970 1973 1976 1979 1982 1985 1988 1991 1994 1997 2000 2003 2006 2009 2012
Percent
Hep A
(2+)
DTP / DTaP(3+)†
MMR(1+)
Hib§
HP 2020 Target*
Hep B
(3+)
Polio (3+)
Varicella (1+)
PCV
(4+)
RV¶
<1% of toddlers received zero doses of vaccines
From Ann
Schuchat
Estimated Return on Investment
of Childhood Vaccines
For each birth cohort vaccinated against 13 diseases
in accordance with the schedule for DTaP, Hib, IPV,
MMR, hep B, Varicella, Hepatitis A, Pneumo-7, and
Rotavirus vaccines: 42,000 lives are saved
20M cases of disease are prevented
13.5 billion dollars in direct costs are saved
68.8 billion dollars in direct plus indirect (societal) costs are saved
For each dollar invested in these vaccinations, $10.20 is saved
Fangjun Zhou et al – National Immunization Conference 2011 Workshop D2
https://cdc.confex.com/cdc/nic2011/webprogram/meeting.html
Preliminary results of updated analysis from Zhou et al, Arch of Ped and Adolesc Med 2005
14
From Ann
Schuchat
Seasonal Influenza Vaccination
Coverage—Last 3 Years
0
10
20
30
40
50
60
70
80
90
100
2009-10 2010-11 2011-12
Children (6m - 17y)
Adults (18+ yrs)
Estimated US influenza vaccination coverage
(BRFSS & NIS), 2011-2012 season
http://www.cdc.gov/flu/professionals/vaccination/coverage_1011estimates.htm
Age Groups % 95% CI
Children
6 mos–17 yrs 51.5 (±1.0)
6–23 mos 74.6 (±2.5)
2–4 yrs 63.3 (±2.3)
5–12 yrs 54.2 (±1.4)
13–17 yrs 33.7 (±1.6)
Adults
18-64 yrs 33.1 (±0.6)
65+ yrs 64.9 (±0.8)
Some child vaccine-preventable
disease still occurs in the US
Measles (outbreaks)
Pertussis (>40,000 cases in 2012)
Influenza (20,000 hospitalizations in children)
But overall we are doing very well!
Pertussis Cases in USA
2000 7867
2001 7580
2002 9771
2003 11651
2004 25827
2005 25619
2006 15631
2007 10454
2008 13278
2009 16858
2010 27550
2011 18719
2012* 41,880
Outline
Burden of childhood vaccine-preventable
disease
Strategies to improve immunization rates
Challenges and methods to overcome challenges
Useful immunization resources
System
Provider
Patient
-No access -Extra visit -Fear -Costs
-Missed opportunities -No reminder/recall -No QA- practice rates -Ordering vaccines
-Vaccine shortages
-No tracking system
-Financing (despite VFC)
-Scattering of care
Barriers to Vaccinations
System
Provider Patient
-No access -Extra visit -Fear -Costs
-Missed opportunities -No reminder/recall -No QA- practice rates -Ordering vaccines
-Vaccine shortages
-No tracking system
-Financing (despite VFC)
-Scattering of care
Barriers to Influenza Vaccinations
Vaccine -Need to vaccinate annually
-Short time window to vaccinate
So what works?
To improve childhood immunizations
Review of the literature and experience
System
Provider Patient
-No access -Extra visit -Fear -Costs
-Missed opportunities -No reminder/recall -No QA- practice rates -Ordering vaccines
-Vaccine shortages
-No tracking system
-Financing (despite VFC)
-Scattering of care
Barriers to Influenza Vaccinations
Vaccine -Need to vaccinate annually
-Short time window to vaccinate
Practice-based interventions to
improve childhood vaccination rates
Intervention Experience Across the US
Patient Reminder-Recall Some practices use it (phone, autodialer, cards)
Clearly helps (5-10%), Challenge for the poor
Provider prompts or standing
orders (to reduce missed
opportunities)
Feasible, fits potentially with EMRs
Not well studied, small benefits
Patient education (provider
recommendations)
“Necessary but not sufficient;” by itself unclear
benefit although clearly needed
Audit-feedback Small benefits
Vaccine champion in office (for
QI changes, policies)
Not studied well but clearly helps
Interweaving vaccinations with
WCC visits
A critical component of success
Summary: Many interventions help, combination of >1 intervention the best
Practice-based interventions to
improve influenza vaccination rates
Intervention Experience Across the US
Patient Reminder-Recall Many practices use it (autodialer phone, cards)
Clearly helps (5-10%)
Flu Vaccine Clinics (e.g.,
Saturdays)
Some benefit; variable success
Relatively small numbers
Patient education (provider
recommendations)
“Necessary but not sufficient;” by itself unclear
benefit although clearly needed
Don’t stop vaccinating too
soon
Not much data, small benefits
Summary: Many interventions help, but won’t raise rates to >80%
System
Provider Patient
-No access -Extra visit -Fear -Costs
-Missed opportunities -No reminder/recall -No QA- practice rates -Ordering vaccines
-Vaccine shortages
-No tracking system
-Financing (despite VFC)
-Scattering of care
Barriers to Influenza Vaccinations
Vaccine -Need to vaccinate annually
-Short time window to vaccinate
Patient-based interventions to
improve childhood vaccination rates
Intervention Experience Across the US
Provide a medical home Clearly important
Not always possible (so alternative sites needed)
Provide access to those without
medical homes (PHCs)
Some evidence, more experience
Educate the public
(benefit of vaccines, fear, side-
effects, myths)
Very important to “increase demand”
Best if combined with other strategies
Needs to be culturally sensitive
Varies by vaccine (eg flu, MMR [autism])
Address costs (also under
“System”)
Not well studied other than VFC
Need to address costs for visit, vaccines, and
indirect costs
Summary: Big role for public health and professional organizations
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System
Provider Patient
-No access -Extra visit -Fear -Costs
-Missed opportunities -No reminder/recall -No QA- practice rates -Ordering vaccines
-Vaccine shortages
-No tracking system
-Financing (despite VFC)
-Scattering of care
Barriers to Influenza Vaccinations
Vaccine -Need to vaccinate annually
-Short time window to vaccinate
System-based interventions to
improve childhood vaccination rates
Intervention Experience Across the US
Provide a tracking system
(immunization registries
Important, can improve rates if combined with
interventions. Inter-changeability with EMRs key
Reduce out-of-pocket costs
VFC is critical, more self-insured plans, ACA
Provide health insurance to all
children
Strong evidence. ACA should help
Provide appropriate
reimbursement
Important for flu and newer vaccines
VFC coverage and national recs. should match
School entry requirements-
laws
Very powerful policy lever
Summary: Build upon current systems and programs. Communicate!
“Hot” research topics
Evaluate interventions – especially in real
world (T3-T4 research)
EMR-based interventions
Influenza vaccine (since rates are low)
Using QI to improve vaccination rates
Vaccine communication and education
With the public
With professionals
Outline
Burden of childhood vaccine-preventable
disease
Strategies to improve immunization rates
Challenges and methods to overcome challenges
Useful immunization resources
New Tools for Clinicians and Parents
Provider Resources for Vaccine Conversations
with Parents
www.cdc.gov/vaccines/conversations
Health Care Professional Home Page
www.cdc.gov/vaccines/hcp
“Get the Picture” Childhood Video
www.youtube.com/user/CDCStreamingHealth
Public awareness campaign launched Niiw 2012
Radio,TV , print PSAs From Ann
Schuchat
Immunization Action Coalition
http://www.immunize.org/
American Academy of Pediatrics (AAP)
http://www2.aap.org/immunization/
Teaching Immunization Delivery and
Evaluation (TIDE)
http://tide.musc.edu/
Task Force on Community Preventive Services http://www.thecommunityguide.org/vaccines/index.html
CDC Immunization Information http://www.cdc.gov/vaccines/ed/default.htm
Summary
Vaccine-preventable diseases still exist for children
E.g., flu, pneumococcal, measles, pertussis, Hepatitis A)
Vaccination rates are high, preventing morbidity!
Barriers to vaccinations do exist:
Provider + Patient + System + vaccine-specific
What works: Strategies to overcome the barriers
Resources: many exist (provided)
Childhood vaccines are a major benefit!
Extra Slides:
Disease Burden
CDC/National Center for Immunization & Respiratory Diseases
Comparison of 20th Century Annual Morbidity and Current Morbidity: Vaccine-Preventable Diseases
Disease
20th Century
Annual Morbidity†
2011
Reported Cases † †
Percent
Decrease
Smallpox 29,005 0 100%
Diphtheria 21,053 0 100%
Measles 530,217 222 > 99%
Mumps 162,344 404 > 99%
Pertussis 200,752 18,719 91%
Polio (paralytic) 16,316 0 100%
Rubella 47,745 4 > 99%
Congenital Rubella Syndrome 152 0 100%
Tetanus 580 36 94%
Haemophilus influenzae 20,000 14* > 99% †Source: JAMA. 2007;298(18):2155-2163 † † Source: CDC. MMWR August 17, 2012;61(32);624-637. (final 2011 data)
* Haemophilus influenzae type b (Hib) < 5 years of age. An additional 14 cases of Hib are estimated to
have occurred among the 226 reports of Hi (< 5 years of age) with unknown serotype.
Measles, United States, 2011
Geographic Distribution of Cases (n=222)
43
= 1 case
MMWR April 20, 2012
Measles Outbreaks*, U.S., 2011
112/222 (50%) annual cases were
outbreak-associated
17 total outbreaks
Median outbreak size was 6 (range: 3 – 21)
44% of outbreak-associated cases occurred
in unvaccinated philosophical belief
exemptors
44
*Outbreak = 3 or more epidemiologically linked cases MMWR April 20, 2012
Whooping cough cases reach epidemic
levels in much of Washington All teens and adults need a whooping cough booster
April 3, 2012 July 20, 2012
Burden of influenza in the US
Annual Burden-All Ages
200,000 hospitalizations 20,000 in children
36,000 deaths 46-153 per year in children
Hundreds of thousands of outpatient visits
During 3m peak flu season, 20-75% of ARI visits
Complications mostly in: <2y, elderly, chronic disease
Rates of Visits Per 1,000
Age Hospital ED Outpt.
0-4.9y* 0.4-0.9 6-27 50-95
5-12y** One-quarter to one-half
of above
NVSN Studies:
* Poehling et al NEJM, 2006
** From NVSN
Influenza-related morbidity & mortality
among healthy people
Glezen WP. Emerging infections: pandemic influenza. Epidemiol Rev. 1996; 18(1),64-76.
<5 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 > 65
Pneumonia-Influenza Mortality
120
80
40
0
Age (Years)
80
40
0
30
20
10
0
Per 100,000
Hospitalizations
Rates
Medically Attended Illness
20
60
Has not changed much since then