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Middleton DB, Lin CJ, Smith KJ, Zimmerman RK, Nowalk MP, Roberts MS, Fox DE. Economic Evaluation of Standing Order Programs for Pneumococcal Vaccination of Hospitalized Elderly Patients. Infect Control Hosp Epidemiol 2015; 29:385-94. [DOI: 10.1086/587155] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background.Standing order programs (SOPs), which allow for vaccination without an individual physician order, are the most effective mechanism to achieve high vaccination rates. Among the suggested settings for the utilization of SOPs are hospital inpatient units, because they provide care for those most likely to benefit from vaccination. The cost-effectiveness of this approach for elderly hospitalized persons is unknown. The purpose of this study was to estimate the cost-effectiveness of SOPs for pneumococcal polysaccharide vaccine (PPV) vaccination for patients 65 years of age or older in 2 types of hospital.Methods.In 2004, a 1,094-bed tertiary care hospital implemented a pharmacy-based SOP for PPV, and a 225-bed community hospital implemented a nursing-based SOP for PPV. Newly admitted patients 65 years of age or older were screened for PPV eligibility and then offered PPV. Vaccination rates before and after initiation of SOPs in the United States, incidence rates of invasive pneumococcal disease in the United States, and US economic data were the bases of the cost-effectiveness analyses. One-way and multivariate sensitivity analyses were conducted.Results.PPV vaccination rates increased 30.5% in the tertiary care hospital and 15.3% in the community hospital. In the base-case cost-effectiveness analysis, using a societal perspective, we found that both pharmacy-based and nursing-based SOPs cost less than $10,000 per quality-adjusted life-year gained, with program costs (pharmacy-based SOPs cost $4.16 per patient screened, and nursing-based SOPs cost $4.60 per patient screened) and vaccine costs ($18.33 per dose) partially offset by potential savings from cases of invasive pneumococcal disease avoided ($12,436 per case). Sensitivity analyses showed SOPs for PPV vaccination to be cost-effective, compared with PPV vaccination without SOPs, unless the improvement in vaccination rate was less than 8%.Conclusion.SOPs do increase PPV vaccination rates in hospitalized elderly patients and are economically favorable, compared with PPV vaccination rates without SOPs.
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Dexheimer JW, Talbot TR, Ye F, Shyr Y, Jones I, Gregg WM, Aronsky D. A computerized pneumococcal vaccination reminder system in the adult emergency department. Vaccine 2011; 29:7035-41. [PMID: 21784117 PMCID: PMC3168965 DOI: 10.1016/j.vaccine.2011.07.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2011] [Revised: 07/01/2011] [Accepted: 07/08/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Pneumococcal vaccination is an effective strategy to prevent invasive pneumococcal disease in the elderly. Emergency department (ED) visits present an underutilized opportunity to increase vaccination rates; however, designing a sustainable vaccination program in an ED is challenging. We examined whether an information technology supported approach would provide a feasible and sustainable method to increase vaccination rates in an adult ED. METHODS During a 1-year period we prospectively evaluated a team-oriented, workflow-embedded reminder system that integrated four different information systems. The computerized triage application screened all patients 65 years and older for pneumococcal vaccine eligibility with information from the electronic patient record. For eligible patients the computerized provider order entry system reminded clinicians to place a vaccination order, which was passed to the order tracking application. Documentation of vaccine administration was then added to the longitudinal electronic patient record. The primary outcome was the vaccine administration rate in the ED. Multivariate logistic regression analysis was used to estimate the odds ratios and their 95% confidence intervals, representing the overall relative risks of ED workload related variables associated with vaccination rate. RESULTS Among 3371 patients 65 years old and older screened at triage 1309 (38.8%) were up-to-date with pneumococcal vaccination and 2062 (61.2%) were eligible for vaccination. Of the eligible patients, 621 (30.1%) consented to receive the vaccination during their ED visit. Physicians received prompts for 428 (68.9%) patients. When prompted, physicians declined to order the vaccine in 192 (30.9%) patients, while 222 (10.8%) of eligible patients actually received the vaccine. The computerized reminder system increased vaccination rate from a baseline of 38.8% to 45.4%. Vaccination during the ED visit was associated younger age (OR: 0.972, CI: 0.953-0.991), Caucasian race (OR: 0.329, CI: 0.241-0.448), and longer ED boarding times (OR: 1.039, CI: 1.013-1.065). CONCLUSION The integrated informatics solution seems to be a feasible and sustainable model to increase vaccination rates in a challenging ED environment.
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Affiliation(s)
- Judith W Dexheimer
- Division of Biomedical Informatics, Eskind Biomedical Library, Vanderbilt University, 2209 Garland Avenue, Nashville, TN 37232-8340, USA.
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Fukuda H, Imanaka Y. Assessment of transparency of cost estimates in economic evaluations of patient safety programmes. J Eval Clin Pract 2009; 15:451-9. [PMID: 19366392 DOI: 10.1111/j.1365-2753.2008.01033.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Transparency of costing is essential for decision-makers who require information on the efficiency of a health care programme, because effective decisions depend largely on applicability to their settings. The main objectives of this study were to assess published studies for transparency of cost estimates. METHODS We first developed criteria with two axes by reviewing publications dealing with economic evaluations and cost accounting studies: clarification of the scope of costing and accuracy of method evaluating costs. We then performed systematic searches of the literature for studies which estimated prevention costs and assessed the transparency and accuracy of costing based on our criteria. RESULTS Forty studies met the inclusion criteria. Half of the studies reported data for both the quantity and unit price of programmes in regard to prevention costs. Although 30 studies estimated costs of adverse events, 19 of these described the scope of costing only, and just five studies used a micro-costing method. Among 30 studies that estimated 'gross cost savings' and 'net cost savings', there was a huge discrepancy in labels. CONCLUSIONS Even if a cost study was conducted in accordance with existing techniques of economic evaluation which mostly paid attention to internal validity of cost estimates, without adequate explanation of the process of costing, reproducibility cannot be assured and the study may lose its value as scientific information. This study found that there is tremendous room for improvement.
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Affiliation(s)
- Haruhisa Fukuda
- Department of Healthare Economics and Quality Management, School of Public Health, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Martin DR, Brauner ME, Plouffe JF. Influenza and pneumococcal vaccinations in the emergency department. Emerg Med Clin North Am 2008; 26:549-70, xi. [PMID: 18406987 DOI: 10.1016/j.emc.2008.02.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Influenza and pneumococcal pneumonia remain among the most significant causes of morbidity and mortality of any of the infectious disease emergencies presenting to emergency departments (EDs). Because the ED has become a recommended location at which immunizations have been administered to prevent several infections, pneumococcal and influenza vaccinations can have an impact on the care of ED patients. ED personnel are uniquely positioned to vaccinate a substantial number of patients who would not otherwise be vaccinated, including many high-risk populations. In addition to decreasing vaccine-preventable mortality and morbidity from influenza and pneumococcal diseases, EDs that implement and monitor a systematic approach to these vaccinations can attenuate ED overcrowding and facilitate patient flow. ED vaccination strategies have been proved to be successful and reimbursable and are advocated by several major clinical practice advisory groups.
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Affiliation(s)
- Daniel R Martin
- Department of Emergency Medicine, The Ohio State University Medical Center, 410 West 10th Avenue, Columbus, OH 43210, USA.
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Skull SA, Andrews RM, Byrnes GB, Kelly HA, Nolan TM, Brown GV, Campbell DA. Missed opportunities to vaccinate a cohort of hospitalised elderly with pneumococcal and influenza vaccines. Vaccine 2007; 25:5146-54. [PMID: 17543426 DOI: 10.1016/j.vaccine.2007.04.082] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2007] [Revised: 04/29/2007] [Accepted: 04/29/2007] [Indexed: 11/26/2022]
Abstract
This study examines missed opportunities for recommended influenza vaccine and 23-valent pneumococcal vaccine (23vPPV) among hospitalised elderly persons. 4772 inpatients aged > or = 65 years (cases of pneumonia and frequency-matched randomly selected cohort subjects) participated from two large tertiary Australian hospitals. For subjects unvaccinated with influenza vaccine (past year), 1110/1115 (99.6%) had visited either a doctor (99.4%, mean 11.2 visits) or the same hospital (52.0%, mean 1.5 visits). For those unvaccinated with 23vPPV (past 5 years), 1809/1813 (99.8%) had visited either a doctor (99.7%, mean 11.2 visits) or the same hospital (51.5%, mean 1.5 times) in the past year; 71% had been admitted to the same hospital in the past 5 years (mean 3.4 times). 2.3% of all subjects had vaccination status recorded. No unvaccinated subject was vaccinated during admission, despite approximately 40% reporting acceptability of vaccination if offered. Previous hospitalisation was a risk factor for being unvaccinated. Barriers to implementation of current vaccination policy in the hospital setting require formal evaluation in Australia.
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Affiliation(s)
- Susan A Skull
- Department of Paediatrics, University of Melbourne, Royal Children's Hospital, Flemington Road, Parkville, Victoria 3052, Australia.
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Dexheimer JW, Jones I, Chen Q, Talbot TR, Mason D, Aronsky D. Providers' beliefs, attitudes, and behaviors before implementing a computerized pneumococcal vaccination reminder. Acad Emerg Med 2006; 13:1312-8. [PMID: 17101730 DOI: 10.1197/j.aem.2006.07.029] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The emergency department (ED) has been recommended as a suitable setting for offering pneumococcal vaccination; however, implementations of ED vaccination programs remain scarce. OBJECTIVES To understand beliefs, attitudes, and behaviors of ED providers before implementing a computerized reminder system. METHODS An anonymous, five-point Likert-scale, 46-item survey was administered to emergency physicians and nurses at an academic medical center. The survey included aspects of ordering patterns, implementation strategies, barriers, and factors considered important for an ED-based vaccination initiative as well as aspects of implementing a computerized vaccine-reminder system. RESULTS Among 160 eligible ED providers, the survey was returned by 64 of 67 physicians (96%), and all 93 nurses (100%). The vaccine was considered to be cost effective by 71% of physicians, but only 2% recommended it to their patients. Although 98% of physicians accessed the computerized problem list before examining the patient, only 28% reviewed the patient's health-maintenance section. Physicians and nurses preferred a computerized vaccination-reminder system in 93% and 82%, respectively. Physicians' preferred implementation approach included a nurse standing order, combined with physician notification; nurses, however, favored a physician order. Factors for improving vaccination rates included improved computerized documentation, whereas increasing the number of ED staff was less important. Relevant implementation barriers for physicians were not remembering to offer vaccination, time constraints, and insufficient time to counsel patients. The ED was believed to be an appropriate setting in which to offer vaccination. CONCLUSIONS Emergency department staff had favorable attitudes toward an ED-based pneumococcal vaccination program; however, considerable barriers inherent to the ED setting may challenge such a program. Applying information technology may overcome some barriers and facilitate an ED-based vaccination initiative.
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Affiliation(s)
- Judith W Dexheimer
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
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Abstract
This study was a retrospective, preintervention and postintervention evaluation of influenza and pneumococcal vaccination among hospitalized patients eligible for vaccination. The authors abstracted 1476 randomly sampled patient charts to compare vaccination before (2002) or after (2003) implementation of vaccination policies in 4 Michigan hospitals. In addition, they assessed completeness of vaccine assessment forms, evaluated reasons for nonvaccination, and conducted interviews with hospital staff. Vaccination increased at 3 of 4 hospitals after implementation of vaccination policies, yet rates remained low (<10% overall; range, 3.4%-12.4%). Vaccine assessment forms were found in most of the charts in 2003, but almost a third were incomplete. Challenges to implementing inpatient vaccination included support and training of hospital staff, interpretation of vaccination recommendations, lack of systematic prompts for vaccinations, and cost reimbursement. These findings underscore the need for continuous quality improvement and process monitoring to determine strategies for overcoming challenges to inpatient vaccination.
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Affiliation(s)
- Carla A Winston
- Health Services Research and Evaluation Branch, National Immunization Program, Centers for Disease Control and Prevention, 1600 Clifton Road, Mailstop E-52, Atlanta, GA 30333, USA.
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Helms CM, Guerra FA, Klein JO, Schaffner W, Arvin AM, Peter G. Strengthening the nation's influenza vaccination system: a National Vaccine Advisory Committee assessment. Am J Prev Med 2005; 29:221-6. [PMID: 16168873 DOI: 10.1016/j.amepre.2005.05.011] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2005] [Revised: 04/06/2005] [Accepted: 05/31/2005] [Indexed: 11/20/2022]
Affiliation(s)
- Charles M Helms
- National Vaccine Advisory Committee, Department of Health and Human Services, Washington DC, USA.
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Pallin DJ, Muennig PA, Emond JA, Kim S, Camargo CA. Vaccination practices in U.S. emergency departments, 1992–2000. Vaccine 2005; 23:1048-52. [PMID: 15620478 DOI: 10.1016/j.vaccine.2004.06.053] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2003] [Revised: 06/28/2004] [Accepted: 06/29/2004] [Indexed: 11/20/2022]
Abstract
To determine how frequently emergency department (ED) patients are vaccinated against influenza and pneumococcus, we analyzed all adult ED vaccinations in the combined databases of the annual National Hospital Ambulatory Medical Care Surveys, 1992-2000. During this period, EDs gave 27,738,000 vaccinations (95%CI: 25,878,000-29,598,000). Of these, 93% (87-100%) were against tetanus. The count of pneumococcal or influenza vaccinations was too small to permit estimation of a national total. Large-scale vaccination of ED patients appears feasible, given the tetanus experience, but ED patients are rarely vaccinated against influenza or pneumococcus. Reasons for this disconnect between burden of disease and preventive practices are discussed.
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Affiliation(s)
- Daniel J Pallin
- Brigham and Women's Hospital, 75 Francis St., Boston, MA 02115, USA.
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Rudis MI, Stone SC, Goad JA, Lee VW, Chitchyan A, Newton KI. Pneumococcal vaccination in the emergency department: An assessment of need. Ann Emerg Med 2004; 44:386-92. [PMID: 15459621 DOI: 10.1016/j.annemergmed.2004.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES Immunization against Streptococcus pneumoniae with the 23-valent pneumococcal polysaccharide vaccine has been shown to be cost-effective for prevention of invasive pneumococcal disease. Yet 23-valent pneumococcal polysaccharide vaccine is widely underused, particularly among ethnic minorities. The objectives of this survey are to determine the rate of 23-valent pneumococcal polysaccharide vaccine vaccination among all adult patients presenting to the emergency department (ED) of a county-based, urban, tertiary care medical center; the willingness of patients to receive 23-valent pneumococcal polysaccharide vaccine; and reasons for nonvaccination. METHODS A quality assurance survey was performed in the ED during 3 days in September 2002. A survey was developed to determine 23-valent pneumococcal polysaccharide vaccine vaccination rates and eligibility according to indications and contraindications established by the Centers for Disease Control and Prevention (CDC). Descriptive statistics were performed to quantify the proportion of patients who were immunized, eligible, and willing to receive 23-valent pneumococcal polysaccharide vaccine and reasons for nonvaccination. RESULTS A total of 250 patients of 1,535 registered in the ED were surveyed during the 3-day period. Only 48 (19%) had a primary care provider. The majority of patients were Hispanic (73%). Only 22 (9%) patients had received the vaccine. A total of 66 (26%) patients fit the CDC eligibility criteria for 23-valent pneumococcal polysaccharide vaccine, and 59 (89%) of these patients were willing to receive the vaccine during their ED visit. Most patients (79%) were eligible to receive 23-valent pneumococcal polysaccharide vaccine due to their comorbid illnesses. CONCLUSION In the ED of our county-based urban medical center, 26% of patients were eligible for 23-valent pneumococcal polysaccharide vaccine; the majority of patients were Hispanic, unaware of the vaccine's existence, and willing to receive it during their ED visit. These data underscore a large unmet public health need among ethnic minorities in the ED.
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Affiliation(s)
- Maria I Rudis
- Department of Pharmacy, School of Pharmacy, Keck School of Medicine, University of Southern California and Los Angeles County+USC Medical Center, Los Angeles, CA 90033, USA.
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