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Offering Free Vaccination Eliminates Disparities in Adult Immunization But Low Cost Vaccination Does Not Free vs. Cheap Daniel B. Fishbein, William B. Cassidy, Dale Bell Marioneaux, Monica Pradhan, Mark Messonnier, Doug Schwalm, Noelle-Angelique Molinari, Carla Winston CDC Bayo Willis

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slide1

Offering Free Vaccination Eliminates Disparities in Adult Immunization But Low Cost Vaccination Does NotFree vs. CheapDaniel B. Fishbein, William B. Cassidy, Dale Bell Marioneaux, Monica Pradhan, Mark Messonnier, Doug Schwalm, Noelle-Angelique Molinari, Carla Winston

collaborators
CDC

Bayo Willis

Edith Gary

Pascale Wortley

Mary McCauley

Ronald Nuse

Task Force on Community Preventive Services

LSU

Pam Saloom

Glenn Jones

Kim Nguyen

Larie Witt

Cathy Henderson

J. Nelson Perrett

Sara D’Autramont

Collaborators

NVPO

institute of medicine
Institute of Medicine
  • “Priorities should shift from documenting disparities to assessing interventions strategies …..that separate the contribution of the patient, provider, and institution.”

“Unequal Treatment”

Institute of Medicine 2002

outline
Outline
  • Why do disparities exist?
  • Study 1: Separating the contribution of the provider in family practice clinics
  • Study 2: Separating the contribution of the provider II: Move to emergency rooms
  • Study 3: Separate the contribution of the institution: Financial disincentives
  • Conclusions
outline5
Outline
  • Why do disparities exist?
  • Study 1: Separating the contribution of the provider in family practice clinics
  • Study 2: Separating the contribution of the provider II
  • Study 3: Separate the contribution of the institution: Financial disincentives
  • Conclusions
racial and ethnic disparities
Racial and Ethnic Disparities
  • “The conditions in which many clinical encounters take place, characterized by high timepressure, cognitive complexity, and pressures for cost containment – may enhance the likelihood (of) care poorly matched to minority patients’ needs”

“Unequal Treatment”

Institute of Medicine 2002

time constraints
Time Constraints

“To fully satisfy the USPSTF recommendations, 1774 hours of physicians annual time, or 7.4 hours per working day, is needed for the provision of preventive services.”

outline8
Outline
  • Why do disparities exist?
  • Study 1: Separating the contribution of the provider I in family practice clinics
  • Study 2: Separating the contribution of the provider II
  • Study 3: Separate the contribution of the institution: Financial disincentives
  • Conclusions
assessment reminder a r tool
Assessment-Reminder (A/R) Tool
  • Assess patients vaccination needs
    • Self- or assisted-administration
  • Reminds patient and provider about indicated vaccinations
separating the contribution of the provider i family practice clinics
Setting

Sample and design

Intervention

Outcome measures

Three family practice clinics, interested physicians, diverse patient populations, many “safety nets” for vaccination

Convenience sample of 100 intervention and 100 control patients at each clinic

Assessment reminder form (6 vaccines) versus exercise promotion

Vaccinations according to chart review

Separating the Contribution of the Provider I: Family Practice Clinics
efficacy of a r tool
Efficacy of A/R Tool

* ‘Indicated’ refers to being at risk (having vaccine specific risk factor) and

not being up to date based on medical record review

outline12
Outline
  • Why do disparities exist?
  • Study 1: Separating the contribution of the provider I: Family practice clinics
  • Study 2: Separating the contribution of the provider II: Move to emergency rooms
  • Study 3: Separate the contribution of the institution: Financial disincentives
  • Conclusions
why emergency departments
Why Emergency Departments?
  • Easier place for us to “separate the contribution of the patient, provider, and institution”
    • Providers primarily focused on the chief complaint and willing to let us focus on prevention
    • Patients who are not critically ill have plenty of time
why emergency departments14
Why Emergency Departments?
  • People who seek primary care in emergency departments ideal target group
    • More likely to be underinsured and therefore under vaccinated
      • Efficiency
    • Have time while waiting in ED, but not during the rest of their lives
trend in emergency department visit rates united states 1992 2001
Trend in Emergency Department Visit Rates United States, 1992-2001

NOTE: Trend is significant (p<0.05).

moving to emergency rooms is every visit a missed opportunity to vaccinate
Setting

Sample and design

Intervention

Outcome measure

Urban emergency department, almost all patients low income, October 2003

Convenience sample of 104 patients randomized to vaccination in the ED versus referral for vaccination

Assessment reminder form (3 vaccines) and standing order

Vaccination

Moving To Emergency Rooms Is Every Visit a Missed Opportunity to Vaccinate?
outline20
Outline
  • Why do disparities exist?
  • Study 1: Separating the contribution of the provider I: Family practice clinics
  • Study 2: Separating the contribution of the provider II: Move to emergency rooms
  • Study 3: Separate the contribution of the institution: Financial disincentives
  • Conclusions
slide21
Setting

Sample and design

Data

Outcome

Urban emergency department, mix of low and middle income, many minority, December 2003-January 2004

600 consecutive patients 18-64 years, assessed by college students, randomized to free vaccine, $5 per shot, or $10 per shot (200 per group)

Assessment reminder form

Acceptance of vaccination

Separate the contribution of the institution: Financial disincentivesWillingness to Pay For Vaccinations
selected characteristics by race
Selected Characteristics, by Race

* Most white but included 7 others; 7 missing

vaccine receipt by race32
Vaccine Receipt, By Race

P=0.003

Chi square

accepted influenza vaccination logistic regression
Accepted Influenza Vaccination, Logistic Regression

Not significant: age, gender, race, Medicaid, income, private insurance,

accepted pneumococcal vaccination logistic regression
Accepted Pneumococcal Vaccination, Logistic Regression

Controlling for age, gender, income, private insurance, Medicaid

accepted hepatitis b vaccination logistic regression
Accepted Hepatitis B Vaccination, Logistic Regression

Controlling for: age, gender, race, income, Medicaid, private insurance

cost analysis
Cost Analysis
  • Total cost
    • Screening, administration, vaccine
    • Influenza: $17.72
    • Pneumococcal: $28.23
    • Hepatitis B: $28.45
cost analysis37
Cost Analysis
  • Supplies (excluding vaccine) : $7.49
  • Labor $3.33
    • Screening, college students (4.8 min)
    • Review and sign order, MD (22 sec.)
    • Administration, RN (5.6 minutes)
  • Vaccines
    • Influenza: $6.90
    • Pneumococcal: $17.41
    • Hepatitis B: $17.63
outline38
Outline
  • Why do disparities exist?
  • Study 1: Separating the contribution of the provider I: Family practice clinics
  • Study 2: Separating the contribution of the provider II: Move to emergency rooms
  • Study 3: Separate the contribution of the institution: Financial disincentives
  • Conclusions
conclusion 1 by ed physician
Conclusion 1: By ED Physician
  • “Everybody wants something for free”
conclusion 2
Conclusion 2
  • By using the A/R form and offering free vaccination in the ED, we were able to overcome many barriers to adult immunization
  • By offering free vaccination in the ED, we were able to increase coverage of influenza and pneumococcal vaccines to levels that exceeded 2010 targets
conclusion 3
Conclusion 3
  • Offering free vaccination eliminates disparities in adult immunization but low cost vaccination does not
  • Many patients, including those with insurance, may be unwilling to pay for immunizations
  • Unless we address out of pocket costs of immunizations, we may be unable to meet our 2010 targets
development as freedom amartya sen 1999
Development as FreedomAmartya Sen, 1999
  • “…..being relatively poor in a rich country can be a great handicap ……even when that person is at a much higher level of income compared with people in less opulent countries.”
  • Development as Freedom
  • Amartya Sen, 1999