Running head: BARRIERS AND STRATEGIES TO VACCINATING ADULTS

Barriers to Vaccinating Adults and the Strategies to Overcome Them Jacqueline D. Grange Brigham Young University

Authors note: J. Grange, March 12, 2014, Nursing 400, Karen Barnhill and Sara Hawkins, BYU-I

BARRIERS AND STRATEGIES TO VACCINATING ADULTS Barriers to Vaccinating Adults and the Strategies to Overcome Them Since 2009 the Assistant Secretary of Health has asked the National Vaccine Advisory Committee (NVAC) to develop a plan that would lead to improving adult immunization

coverage and thus reduce preventable diseases in adults as had been mirrored with the childhood immunization programs of the past. Barriers to adults receiving vaccinations were identified at that time and strategic plans began to develop (National Vaccine Advisory Committee NVAC, 2011) (NVAC, 2013). Barriers Nine categories of barriers were identified to include a lack of public knowledge, lack of coordination of adult immunization activities, lack of provider recommendations for immunization, financial impediments to vaccinations, lack of access to and utilization of, healthcare services by adults, lack of utilization and reminder or assessment systems, racial and ethnic disparities, health literacy, and concern about adverse events (NVAC, 2011) (Pickering et al., 2009). The 2013 NVAC report updated some of these barriers. Specifically there is a lack of health care provider and patient knowledge about the need for vaccinating both healthy and high risk adults. Medical management has traditionally focused on acute and chronic illnesses rather than preventative. Although Medicare covers most vaccinations under the B plan as a vaccination, it covers zoster and Tdap under the D plan which is billed differently as a drug and complicates patients receiving the latter two mentioned. Medicaid vaccination coverage varies by state with some states only covering part of the Advisory Committee of Immunization Practice (ACIP) recommendations. Out of pocket costs and adults without one primary care provider complicate the coordination of vaccine management. Many groups are working closely

BARRIERS AND STRATEGIES TO VACCINATING ADULTS with the Center for Disease Control and Prevention (CDC) to initiate strategies to overcome the obstacles that prevent adults from receiving necessary and potentially lifesaving immunizations. Strategies to Improve Vaccination Uptake Knowing the technical and scientific information about vaccinations is not enough to increase vaccination rates. Studies have shown that administrative strategies with a systems approach involving all the office staff in the planning and decision making process works best (CDC, 2014). One of the most important predictors of receipt of vaccinations among adults is that of a

recommendation from the patients health care provider (Johnson, Nichols, & Lipczynski, 2008) (NVAC, 2013). Thus in every encounter with patients, healthcare providers must take the initiative to indicate that the patients doctor recommends that they get up to date on the vaccinations for adults. A strategy to help with this is having standing orders for the immunizations. Other strategies are computerized record reminders, chart reminders, performance feedback, home visits, mailed or telephone reminders, patient education, personal health records and expanding access to health care settings. Standing Orders Standing orders are a written order stipulating that all persons meeting certain criteria should be vaccinated. This eliminates a provider having to write an order for each patient allowing non-provider personnel to deliver a vaccination following protocol. It is the most efficient method for increasing adult vaccination rates and is easy to implement. One study, cited by the CDC (2014), performed in outpatient clinics found that vaccination rates of

BARRIERS AND STRATEGIES TO VACCINATING ADULTS influenza increased from 29 to 81 percent using standing orders (Margolis, Lofgren & Korn, 1988). Computerized Record Reminders The computer generated record reminders can be printed ahead of a patient appointment and given to the patient prior to visiting the provider so the patient may review certain preventative measures that are due or past due and choose to have them performed at the very appointment. Efficacy using chart reminders was demonstrated by Payne et al., (1995) to increase pneumococcal vaccination rates in high risk adults from 29 percent to 86. Performance Feedback

This is a retrospective evaluation of provider delivery of vaccinations in comparison to an assessed goal or benchmark for a given population. Friendly competition can be instigated between different providers to create incentive. Sixty six percent of patients were vaccinated in a public clinic among clinicians who used this target based approach compared to 50 percent control group who did not (Buffington, Bell & La Force, 1991). Home Visits Home visits can involve the assessment of vaccine services to be received elsewhere, or can be delivery of the shot in the home of the client. Only modest increases have been shown through home visits. Mailed or Telephone Reminders This is a phone or mail contact to notify the patient that a vaccination is due and to schedule an appointment. The advantage of calling is that the appointment can be made over the phone. In a randomized control study McDowell, Newell, & Rosser, (1986) found that 37 percent of clients received the influenza vaccine compared to 9.8% in a control group.

BARRIERS AND STRATEGIES TO VACCINATING ADULTS Patient Education Every medical encounter with a patient should include education. It may look like the patient being handed vaccine information sheets upon admission to their appointment with a consent form that they could read through and then discuss with their provider during the visit. The doctor could quickly answer any questions or concerns and then the medical assistant or nurse could administer the immunizations. Personal Health Records Personal health records (PHR) are given to the patient at the appointment time or mailed

beforehand with a preventative care schedule. This method empowers patients to be proactive in their health care, but is not highly effective with low health literacy populations. Pneumococcal vaccination rates jumped about 15 percent in a study by Dickey & Petitti (1992) comparing with a group with no PHR. Expanding Access to Health Care Settings Expanding access can include increasing or making the hours and services more convenient to receive care, reducing miles patients need to travel to receive vaccinations, reducing administration barriers such as having drop in clinics or express lane vaccination services. Combining this strategy with others can increase outcomes. A study combining telephone reminders and express access to vaccinations increased the rate from 26.8% to 50.8% when comparing to informing patients about the vaccination while in the office (Lukasik &Pratt, 1987). Financial Barriers When patients were surveyed, financial barriers did not surface as a deterrent to immunizations. Consumers said they would be willing to pay up to 30 dollars for a vaccination

BARRIERS AND STRATEGIES TO VACCINATING ADULTS (Johnson et al.,2008). Zoster and Tdap are billed under Medicare D which is billed through

pharmacies. Clinics which do not operate a pharmacy have experienced problems in the delivery of these vaccines if they are given at the clinic. The patients end up with a large bill for the Zoster which has created confusion for a vaccine that is to be mostly covered by Medicare. Merck drug representatives suggested sending all Medicare patients to the pharmacy with a prescription for the Zoster and Tdap which has helped to increase these two vaccination deliveries in the Washington State clinics. Immunization Successes Incorporating the suggested and tried strategies in clinics with the willing participation of all office staff can mean more adults protected by the uptake of vaccinations. More adults immunized means more children protected which can lead to healthier attitudes and communities.

BARRIERS AND STRATEGIES TO VACCINATING ADULTS References Buffington, J., Bell, K., & LaForce, F. ( 1991). A target-based model for increasing influenza immunizations in private practice. Genesee Hospital Medical Staff. Journal of General Internal Medicine, 6,204-209. Center for Disease Control and Prevention. (2014). What works: Strategies to increase adult vaccination rates. Retrieved from http://www2a.cdc.gov/vaccines/ed/whatworks/strategies.asp Dickey, L., & Petitti, D. (1992). A patient-held mini-record to promote adult preventive care. Journal of Family Practice, 34, 457-63. Johnson, R., Nichol, K., & Lipczynski, K. (2008). Barriers to adult immunization. American Journal of Medicine, 121, S28-S35. Retrieved from http://www.immunizeadultga.org/docs/Barriers_to_Adult_Immunization.pdf Lukasik, M., & Pratt, G. (1987). The telephone: an overlooked technology for prevention in family medicine. Canadian Family Physician, 33, 1997-2001. Payne, T., Galvin, M., Taplin, S., Austin, B., Savarino, J.,& Wagner, E. (1995) Practicing population-based care in an HMO: evaluation after 18 months. HMO Practice, 9, 101-110. Retrieved from http://www2a.cdc.gov/vaccines/ed/whatworks/pdfs/ Pickering, L., Baker, C., Freed, G., Gall, S., Grogg, S., Poland, G,Orenstein, W. (2009) Immunization programs for infants, children, adolescents, and adults: Clinical practice guidelines by the infectious disease society of America. Clinical Infectious Diseases, 49, 817-840. doi: 1086/605430 Margolis, K., Lofgren, R., & Korn, J. (1988). Organizational strategies to improve influenza vaccine delivery. Archives of Internal Medicine,148, 2205-2207. Retrieved from

BARRIERS AND STRATEGIES TO VACCINATING ADULTS http://www2a.cdc.gov/vaccines/ed/whatworks/pdfs/referencelist.pdf McDowell, I., Newell, C., & Rosser, W. (1986). Comparison of three methods of recalling

patients for influenza vaccination. Canadian Medical Association Journal, 135, 991-997. National Vaccine Advisory Committee (NVAC). (2011). A pathway to leadership for adult immunization: Recommendations of the national vaccine advisory committee. Retrieved from http:// Retwww.publichealthreports.org/issueopen.cfm?articleID=2762 National Vaccine Advisory Committee (NVAC). (2013). Recommendations from the national vaccine advisory committee: Standards for adult immunization practice 1. Retrieved from http://www.hhs.gov/nvpo/nvac/reports/nvacstandards.pdf