Highlights
- •Standing orders provide a starting point for improving adult immunization coverage.
- •Sustaining higher adult immunization rates needs intervention beyond standing order.
- •Prioritization of adult immunization is challenging without incentives.
- •Better integration of clinic and state data may increase adult immunization rates.
Background
Methods
Results
Conclusions
Key Words
Office of Disease Prevention and Health Promotion. Healthy people 2020 immunization and infectious diseases. Available from: https://www.healthypeople.gov/2020/topics-objectives/topic/immunization-and-infectious-diseases. Accessed February 8, 2018.
Centers for Disease Control and Prevention. Estimates of influenza vaccination coverage among adults—United States, 2017–18 flu season. Available from:https://www.cdc.gov/flu/fluvaxview/coverage-1718estimates.htm. Accessed November 12, 2018.
Centers for Disease Control and Prevention. Standards for Practice.Adult vaccine administration and referral. Available from: https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/referral.html. Accessed March 1, 2018.
Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Washington D.C. Public Health Foundation, 2015, Chapter 6. Available from:https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/vac-admin.pdf. Accessed September 18, 2019.
Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Hamborsky J, Kroger A, Wolfe S, eds. 13th ed. Washington D.C. Public Health Foundation, 2015, Chapter 6. Available from:https://www.cdc.gov/vaccines/pubs/pinkbook/downloads/vac-admin.pdf. Accessed September 18, 2019.
New Hampshire Department of Health and Human Services. NH Department of Health and Human Services applauds legislature's vote to approve immunization registry. Available from:https://www.dhhs.nh.gov/media/pr/2016/05262016registry.htm. Accessed October 31, 2018.
Ofstead CL. The Value of Worksite-based Influenza Vaccination Campaigns Targeting Both Employees and Families. Presented at the National Influenza Vaccine Summit, Atlanta GA, May 17, 2012. Available from: https://www.izsummitpartners.org/content/uploads/2012/NIVS/NIVS-3_ofstead_worksite.pdf. Accessed September 18, 2019.
Community Preventive Services Task Force. Increasing appropriate vaccination: standing orders. Task force finding and rationale statement. Available from:https://www.thecommunityguide.org/sites/default/files/assets/Vaccination-Standing-Orders.pdf.Accessed February 9, 2018.
Department of Health and Human Services. Change in requirement for signed physician's order for influenza and pneumonia vaccine. Available from:https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/downloads/SCLetter03-02.pdf. Accessed February 9, 2018.
Centers for Disease Control and Prevention. Standards for Practice.Adult vaccine administration and referral. Available from: https://www.cdc.gov/vaccines/hcp/adults/for-practice/standards/referral.html. Accessed March 1, 2018.
Community Preventive Services Task Force. Increasing appropriate vaccination: standing orders. Task force finding and rationale statement. Available from:https://www.thecommunityguide.org/sites/default/files/assets/Vaccination-Standing-Orders.pdf.Accessed February 9, 2018.
Methods
Results
Site A | Site B | Site C | Site D | Site E | |
---|---|---|---|---|---|
Specialty | Primary care | OB/GYN | Primary care | Primary care | Primary care |
Implementation start dates | August 15, 2016 | September 19, 2016 | October 20, 2016 | July 1, 2016 | October 31, 2016 |
Number of adult patients | 2000-3500 | 2000-3500 | 7500+ | 5000-7500 | 3500-5000 |
Location (state) | PA | DC | FL | CA | ND |
Community size | Suburban | Urban | Suburban | Rural | Suburban |
Health system affiliation | No | No | Yes | No | Yes |
Ownership | For-profit | For-profit | Mixed | Nonprofit | Nonprofit |
Patient ages | |||||
Under 25 | 13% | 8% | 4% | 8% | 24% |
25-44 | 37% | 65% | 23% | 22% | 26% |
45-64 | 32% | 22% | 44% | 40% | 32% |
65-74 | 10% | 5% | 18% | 17% | 10% |
75+ | 8% | 1% | 11% | 13% | 8% |
Patient sex | |||||
Male | 55% | 0% | 47% | 42% | 47% |
Female | 45% | 100% | 53% | 58% | 53% |
Patient race | |||||
White | 46% | 61% | 55% | 96% | 92% |
African American | 2% | 17% | 15% | 0% | 2% |
Asian | 50% | 5% | 1% | 1% | 0% |
Latino/a | 1% | 2% | 8% | 0% | 4% |
Other | 2% | 15% | 21% | 3% | 3% |
Vaccination rates comparison: Baseline versus intervention year
Site A | Site B | Site C | Site D | Site E | ||||||
---|---|---|---|---|---|---|---|---|---|---|
Pre | Post | Pre | Post | Pre | Post | Pre | Post | Pre | Post | |
Influenza | 44% | 48% | 3% | 9% | 51% | 54% | 18% | 16% | 50% | 51% |
Tdap (aged 19-64 years) | 20% | 39% | 0% | 1% | 53% | 59% | 24% | 30% | 76% | 80% |
Tdap (aged ≥65 years) | 8% | 12% | _ | _ | _ | _ | 33% | 38% | 75% | 77% |
PPSV23 (aged ≥65 years) | _ | _ | _ | _ | 63% | 62% | 21% | 26% | 82% | 82% |
PPSV23 (high-risk † aged 19-64 years)High-risk indications per Advisory Committee on Immunization Practices guidelines were as follows: PPSV23: Chronic heart disease, receiving hemodialysis, end-stage renal disease, chronic lung disease, chronic alcoholism, chronic liver disease, asplenia, diabetes; PCV13: Receiving hemodialysis, end-stage renal disease, asplenia; Hepatitis B: Receiving hemodialysis, end-stage renal disease, chronic liver disease, diabetes, HIV. | _ | _ | _ | _ | _ | _ | 10% | 23% | 24% | 60% |
PCV13 (aged ≥65 years) | _ | _ | _ | _ | 84% | 72% | 28% | 36% | 71% | 75% |
PCV13 (high-risk † aged 19-64 years)High-risk indications per Advisory Committee on Immunization Practices guidelines were as follows: PPSV23: Chronic heart disease, receiving hemodialysis, end-stage renal disease, chronic lung disease, chronic alcoholism, chronic liver disease, asplenia, diabetes; PCV13: Receiving hemodialysis, end-stage renal disease, asplenia; Hepatitis B: Receiving hemodialysis, end-stage renal disease, chronic liver disease, diabetes, HIV. | _ | _ | _ | _ | _ | _ | 4% | 100% | 30% | 41% |
Herpes zoster (aged 60-64 years) | _ | _ | _ | _ | 37% | 42% | _ | _ | 45% | 52% |
Herpes zoster (aged ≥65 years) | _ | _ | _ | _ | _ | _ | _ | _ | 58% | 61% |
Hepatitis B (high-risk † aged ≥19 years who completed series)High-risk indications per Advisory Committee on Immunization Practices guidelines were as follows: PPSV23: Chronic heart disease, receiving hemodialysis, end-stage renal disease, chronic lung disease, chronic alcoholism, chronic liver disease, asplenia, diabetes; PCV13: Receiving hemodialysis, end-stage renal disease, asplenia; Hepatitis B: Receiving hemodialysis, end-stage renal disease, chronic liver disease, diabetes, HIV. | _ | _ | _ | _ | _ | _ | _ | _ | 8% | 8% |
HPV (women aged 19-26 years who completed series) | _ | _ | _ | _ | _ | _ | _ | _ | 46% | 48% |
HPV (men aged 19-26 years who completed series) | _ | _ | _ | _ | _ | _ | _ | _ | 12% | 24% |


Challenges in achieving and sustaining increased adult vaccination coverage rates
Reported by sites | Challenges in achieving and sustaining increased adult vaccination rates |
---|---|
All sites | EMRs had varied capability to provide administrative data required for reporting on adult immunization. |
All sites | EMRs were unable to easily implement clinical decision support systems. It was difficult to program EMRs to identify risk-based patients eligible for immunizations. |
All sites | Medicare Part D coverage of Tdap and zoster vaccines was a barrier to vaccine administration. Patients over age 65 years were referred to pharmacies for Tdap and zoster, but many patients did not receive recommended vaccines. |
A, B, C, D | Sites experienced suboptimal access to adult immunization histories via EMR systems and state IIS. Not all providers report vaccine administration of adults and not all providers have real-time access to IIS to allow uploading or downloading of patient history. |
A, B, C, D | There was reluctance by providers to vaccinate adult patients without documented vaccination history due to financial risk. |
B, C, D | Doctors and advanced care practitioners have limited time with each patient to provide vaccination and other preventive care services. |
B, C, D | Nursing staff workflow (rooming patients, taking vitals, etc) allowed little time for vaccination-related activities. |
C, D | Champions reported a lack of engagement by staff and speculated this could be owing to a lack of incentives (gift cards, pay differentials, additional paid time off, etc) for additional responsibilities. |
C, D | There was low prioritization of adult immunization by administrators and providers because results did not contribute to current quality metrics. |
Discussion
Community Preventive Services Task Force. Increasing appropriate vaccination: health care system-based interventions implemented in combination. Available from:https://www.thecommunityguide.org/sites/default/files/assets/Vaccination-Community-Based-in-Combination.pdf. Accessed February 15, 2018.
Centers for Disease Control and Prevention. Recommended immunization schedule for adults aged 19 years or older, United States, 2019. Available from: https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html. Accessed September 18, 2019.
Centers for Disease Control and Prevention. Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger, United States, 2019. Available from:https://www.cdc.gov/vaccines/schedules/hcp/imz/child-adolescent.html. Accessed September 18, 2019.
Centers for Disease Control and Prevention. Recommended immunization schedule for adults aged 19 years or older, United States, 2019. Available from: https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html. Accessed September 18, 2019.
Community Preventive Services Task Force. Increasing appropriate vaccination: standing orders. Task force finding and rationale statement. Available from:https://www.thecommunityguide.org/sites/default/files/assets/Vaccination-Standing-Orders.pdf.Accessed February 9, 2018.
Community Preventive Services Task Force. Increasing appropriate vaccination: health care system-based interventions implemented in combination. Available from:https://www.thecommunityguide.org/sites/default/files/assets/Vaccination-Community-Based-in-Combination.pdf. Accessed February 15, 2018.
Centers for Medicare & Medicaid Services. Overview of the CMS Meaningful Measures Initiative. Available from:https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/QualityInitiativesGenInfo/Downloads/CMS-Meaningful-Measures_Overview-Fact-Sheet_508_2018-02-28.pdf. Accessed October 1, 2018.
NCQA. Updates quality measures for HEDIS 2019-NCQA. Available from:https://www.ncqa.org/news/ncqa-updates-quality-measures-for-hedis-2019/. Accessed February 25, 2019.
Connection of IIS and EMRs to adult immunization coverage rates
Centers for Disease Control and Prevention. Recommended immunization schedule for adults aged 19 years or older, United States, 2019. Available from: https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html. Accessed September 18, 2019.
Centers for Disease Control and Prevention. Pneumococcal vaccine timing for adults. Available from: https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf. Accessed September 18. 2019.
Centers for Disease Control and Prevention. Recommended immunization schedule for adults aged 19 years or older, United States, 2019. Available from: https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html. Accessed September 18, 2019.
Impact of Medicare Part D on adult immunization coverage rates
Significant adult immunization coverage rates achieved on a large scale combining SOPs and other interventions
Groom A. Fourth Quarter FY 2017 Immunization Report. Available from: https://www.ihs.gov/sites/epi/themes/responsive2017/display_objects/documents/vaccine/reports/FY17_4thQuarter.pdf. Accessed September 18, 2019.
Limitations
Conclusions
Acknowledgements
References
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Article Info
Publication History
Footnotes
Funding/support: Funding for the Take a Stand program and this study of program effectiveness was provided by Pfizer Inc. as part of a multiyear collaboration agreement with the Immunization Action Coalition. Pfizer did not provide workshop content, have contact with study participants, or participate in data collection or analysis. In addition, Pfizer did not provide any free or discounted vaccines to study sites. Participating institutions were not required to use any particular products for adult vaccination.
Conflicts of interest: None to report.
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