Association of State Laws and Healthcare Workers' Influenza Vaccination Rates.

State laws are being used to increase healthcare worker (HCW) influenza vaccine uptake. Approximately 40% of states have enacted such laws but their effectiveness has been infrequently studied. Data sources for this study were the 2000-2011 U.S. National Health Interview Survey Adult Sample File and a summary of U.S. state HCW influenza vaccination laws. Hierarchical linear modeling was used for two time periods: 1) 2000-2005 (before enactment of many state laws) and 2) 2006-2011 (a time of increased enactment of state HCW influenza vaccination legislation). During 2000-2005, two states had HCW influenza vaccination laws and HCW influenza vaccination rates averaged 22.5%. In 2006-2011, 19 states had such laws and vaccination rates averaged 50.9% (p < 0.001). The likelihood of HCW vaccination increased with the scope and breadth, measured by a law score. Although laws varied widely in scope and applicability, states with HCW influenza vaccination laws reported higher HCW vaccination rates.

Cost-effectiveness of procalcitonin-guided antibiotic use in community acquired pneumonia.

BACKGROUND: Although prior randomized trials have demonstrated that procalcitonin-guided antibiotic therapy effectively reduces antibiotic use in patients with community-acquired pneumonia (CAP), uncertainties remain regarding use of procalcitonin protocols in practice. OBJECTIVE: To estimate the cost-effectiveness of procalcitonin protocols in CAP. DESIGN: Decision analysis using published observational and clinical trial data, with variation of all parameter values in sensitivity analyses. PATIENTS: Hypothetical patient cohorts who were hospitalized for CAP. INTERVENTIONS: Procalcitonin protocols vs. usual care. MAIN MEASURES: Costs and cost per quality adjusted life year gained. KEY RESULTS: When no differences in clinical outcomes were assumed, consistent with clinical trials and observational data, procalcitonin protocols cost $10-$54 more per patient than usual care in CAP patients. Under these assumptions, results were most sensitive to variations in: antibiotic cost, the likelihood that antibiotic therapy was initiated less frequently or over shorter durations, and the likelihood that physicians were nonadherent to procalcitonin protocols. Probabilistic sensitivity analyses, incorporating procalcitonin protocol-related changes in quality of life, found that protocol use was unlikely to be economically reasonable if physician protocol nonadherence was high, as observational study data suggest. However, procalcitonin protocols were favored if they decreased hospital length of stay. CONCLUSIONS: Procalcitonin protocol use in hospitalized CAP patients, although promising, lacks physician nonadherence and resource use data in routine care settings, which are needed to evaluate its potential role in patient care.

Cost-effectiveness of adult vaccination strategies using pneumococcal conjugate vaccine compared with pneumococcal polysaccharide vaccine.

CONTEXT: The cost-effectiveness of 13-valent pneumococcal conjugate vaccine (PCV13) compared with 23-valent pneumococcal polysaccharide vaccine (PPSV23) among US adults is unclear. OBJECTIVE: To estimate the cost-effectiveness of PCV13 vaccination strategies in adults. DESIGN, SETTING, AND PARTICIPANTS: A Markov state-transition model, lifetime time horizon, societal perspective. Simulations were performed in hypothetical cohorts of US 50-year-olds. Vaccination strategies and effectiveness estimates were developed by a Delphi expert panel; indirect (herd immunity) effects resulting from childhood PCV13 vaccination were extrapolated based on observed PCV7 effects. Data sources for model parameters included Centers for Disease Control and Prevention Active Bacterial Core surveillance, National Hospital Discharge Survey and Nationwide Inpatient Sample data, and the National Health Interview Survey. MAIN OUTCOME MEASURES: Pneumococcal disease cases prevented and incremental costs per quality-adjusted life-year (QALY) gained. RESULTS: In the base case scenario, administration of PCV13 as a substitute for PPSV23 in current recommendations (ie, vaccination at age 65 years and at younger ages if comorbidities are present) cost $28,900 per QALY gained compared with no vaccination and was more cost-effective than the currently recommended PPSV23 strategy. Routine PCV13 at ages 50 and 65 years cost $45,100 per QALY compared with PCV13 substituted in current recommendations. Adding PPSV23 at age 75 years to PCV13 at ages 50 and 65 years gained 0.00002 QALYs, costing $496,000 per QALY gained. Results were robust in sensitivity analyses and alternative scenarios, except when low PCV13 effectiveness against nonbacteremic pneumococcal pneumonia was assumed or when greater childhood vaccination indirect effects were modeled. In these cases, PPSV23 as currently recommended was favored. CONCLUSION: Overall, PCV13 vaccination was favored compared with PPSV23, but the analysis was sensitive to assumptions about PCV13 effectiveness against nonbacteremic pneumococcal pneumonia and the magnitude of potential indirect effects from childhood PCV13 on pneumococcal serotype distribution.

Understanding adult vaccination in urban, lower-socioeconomic settings: influence of physician and prevention systems.

PURPOSE: Vaccination rates for pneumococcal polysaccharide vaccine (PPV) and influenza vaccine are relatively low in disadvantaged urban populations. This study was designed to assess which physician and practice characteristics might explain differences in rates across physicians. METHODS: PPV and influenza vaccination rates were determined for 2,021 patients aged 65 years and older receiving care from 30 physicians in 17 practices surveyed about their office systems for providing adult immunizations. Hierarchical linear modeling (HLM) analyses were used to examine the relationships among vaccination rates, patient-level characteristics, and physician variables. RESULTS: Overall, the weighted PPV vaccination rate was 60.0% and varied widely across physicians (range, 11%-98%). At the patient level in HLM, patient race (P=.01) and age (P = .02), but not neighborhood income, were associated with PPV status. By linking physician survey data with PPV rates, we found the best pair of physician variables to be "reported time spent with patients for a well visit" (P = .01) and "use of enhanced immunization documentation" (P=.10). The overall influenza vaccination rate was 51.9% (range, 22%-96%). Patient race (P=.003) and age (P = .002) were associated with influenza vaccination. The pair of physician variables with the strongest association with influenza vaccination was "use of standing orders" (P <.001) and "average observed physician examination room time," regardless of visit type (P=.02). CONCLUSIONS: Vaccination rates vary widely in urban settings and are associated with practice characteristics such as time spent with patients and, for influenza vaccine, use of standing orders.

Using quantitative and qualitative approaches to understand racial disparities in adult vaccination.

BACKGROUND: One proposed explanation for the persistence of racial disparities in adult immunizations is that minority patients receive primary care at practices that differ substantively from practices where white patients receive care. This study used both quantitative and qualitative methods to assess physician and practice factors contributing to disparities in a sample of inner-city, urban, and suburban practices in low to moderate income neighborhoods. METHODS: Pneumococcal polysaccharide vaccine (PPV) and influenza vaccination rates were determined from medical record review in a sample of 2021 elderly (aged > or = 65 years) patients. Their physicians were surveyed about office systems for adult immunizations and structured observations of practice physical features, and operations were conducted. Case studies of practices with lowest and highest rates and the largest racial disparities are presented. RESULTS: Overall, weighted PPV vaccination rate was 60%, but rates differed significantly by race (65.8% for whites vs 36.5% for minorities, P < .001 by stratified Cochran-Mantel-Haenszel test). Two of 6 minority panels had PPV rates less than 20%. Overall, weighted influenza vaccination rate, as measured by receipt of the vaccine in 3 of the 5 most recent seasons, was 51.9%, but rates also differed significantly by race (55.6% for whites vs 36.2% for minorities, P < .03, by stratified Cochran-Mantel-Haenszel test). CONCLUSIONS: Low rates in 2 minority panels, racial disparity between minorities and whites in mixed panels, and between-panel variation in rates contributed to the overall differences in vaccination rates by race.

Determinants of adult vaccination at inner-city health centers: a descriptive study.

BACKGROUND: Pneumococcal polysaccharide vaccination rates among adults 65 years and older or less than 65 years with high risk medical conditions are still below Healthy People 2010 recommended levels of 90%. This study was designed to: 1) assess self-reported pneumococcal vaccination rates following health center level interventions to increase adult vaccination rates; and 2) determine factors associated with vaccination. METHODS: Tailored interventions to increase immunizations were implemented at two inner-city health centers. We surveyed 375 patients 50 years of age and older. Multivariate logistic regression examines the predictors of 1) self-reported pneumococcal vaccination and 2) combined self-reported influenza and pneumococcal vaccination. Both of these models were stratified by age group (50-64 years and 65 years and older). RESULTS: Pneumococcal vaccination rates were 45% by self-report, 55% by medical record review, 69% for patients 65 years old and older, 32% for patients 50-64 years; they did not differ by race. Receipt of the previous season's influenza vaccine was significantly related to pneumococcal vaccination among both younger and older patients. Receiving both the pneumococcal vaccine and the most recent influenza vaccine compared with receiving neither, among younger patients was related to unemployment, more frequent physician visits, and belief that those who do not receive the flu shot are more susceptible to the flu. For older patients, receipt of both vaccines was related to nonsmoking status, believing that friends/family think the patient should be vaccinated, seeing posters advertising flu shot clinics, and belief that those who do not receive the flu shot are more susceptible to the flu. CONCLUSION: Our findings suggest that improving overall pneumococcal vaccination rates among eligible adults, has the potential to eliminate racial disparities. Interventions delivering vaccination messages specific to older and younger adult groups may be the best strategy for improving adult vaccination rates.

Racial differences in beliefs about genetic screening among patients at inner-city neighborhood health centers.

BACKGROUND: Genetic testing has the potential to identify persons at high risk for disease. Given the history of racial disparities in screening, early detection and accessing treatment, understanding racial differences in beliefs about genetics is essential to preventing disparities in some conditions. METHODS: In 2004, a sample of older adult patients from four inner-city health centers was surveyed to assess beliefs about genetic determinants of disease, genetic testing and religion. Logistic regression determined which beliefs were associated with race. RESULTS: Of the 314 respondents, 50% were African Americans. Most respondents thought that sickle cell disease, cystic fibrosis and diabetes are primarily genetic. African Americans were more likely than Caucasians to believe that genetic testing will lead to racial discrimination (Odds ratio (OR): 3.02, 95% confidence interval (CI): 1.5-6.0) and to think that all pregnant women should have genetic tests (OR=3.8, 95% CI: 1.7-8.6). African Americans were more likely to believe that God's Word is the most important source for moral decisions (OR: 3.6, 95% CI :1.5-8.7). CONCLUSION: African Americans and Caucasians differ in beliefs about genetic testing and the basis for moral decision-making. Acknowledging and understanding these differences may lead to better medical care.

Parental perspectives on influenza vaccination of children with chronic medical conditions.

BACKGROUND: Minorities and those living in the inner city have a higher respiratory disease burden than other groups. Yet, influenza vaccination rates among all children with chronic medical conditions remain low. METHODS: Parents of 2-13-year-old children with high-risk medical conditions from health centers in low-income urban neighborhoods completed a mailed survey. Immunization status from medical records was used to calculate validity measures. Survey data are presented for those whose vaccination status was concordant between parental report and the medical record (n=183). RESULTS: Parent-reported influenza vaccination versus medical record review showed 84.9% sensitivity, 68.7% specificity, 49.1% positive predictive value and 92.7% negative predictive value, with a kappa of 0.43. Vaccination rate was 30.6%. Medical record-verified influenza vaccination was associated with parental beliefs that the doctor recommends a flu shot (OR, 40.9; 95% Cl, 9.0-184.9) and that relatives recommend a flu shot (OR, 4.3; 95% Cl, 1.7-10.5), and was less likely if the parent believed that the child will get the flu if a household member is infected (OR, 0.2; 95% Cl, 0.1-0.6). CONCLUSIONS: The message that influenza vaccination is important to protect children with chronic medical conditions may be relayed through physician recommendation or a relative's suggestion and may be more effective if it addresses vaccine efficacy issues.

Are plasma mineral levels related to antibody response to influenza vaccination in older adults?

INTRODUCTION: An effective immune response to vaccination may be related to nutritional status. This study examined the association of plasma mineral levels with hemagglutination inhibition (HI) titers produced in response to influenza vaccine in older adults. METHODS: Prior to (Day 0) and 21 (range = 19-28) days after receiving the 2013-14 influenza vaccine, 109 adults ages 51-81 years, provided blood samples. Serum samples were tested for HI activity against the A/H1N1 and A/H3N2 2013-2014 vaccine virus strains. Plasma minerals were collected in zinc-free tubes and assayed by inductively coupled plasma mass spectrometry. HI titers were reported as seroprotection (≥1:40) and seroconversion (≥ 4-fold rise from Day 0 (minimum HI = 1:10) to Day 21). Both HI titers and mineral values were skewed and thus log2 transformed. Magnesium (Mg), phosphorus (P), zinc (Zn), copper (Cu), iron (Fe), potassium (K) and the Cu to Zn ratio were tested. Logistic regression analyses were used to determine the associations between mineral levels and seroconversion and seroprotection of HI titers for each influenza A strain. RESULTS: Participants were 61% white, 28% male, 39% diabetic, and 81% overweight/obese with a mean age of 62.6 y. In logistic regression, Day 21 A/H1N1 seroprotection was associated with P and Zn at Day 21(P < 0.05). Seroconversion of A/H1N1 was associated with Day 21 Cu, P, and Mg (P < 0.03). Day 21 A/H3N2 seroprotection and seroconversion were associated with Day 21 P (P < 0.05). CONCLUSIONS: Phosphorus was associated with seroprotection and seroconversion to influenza A after vaccination; these associations warrant additional studies with larger, more diverse population groups.

What predicts influenza vaccination status in older Americans over several years?

OBJECTIVES: To examine the correlates of repeat influenza vaccination and determine whether there are age-group (50-64, > or =65) differences in decision-making behavior. DESIGN: Longitudinal survey study. SETTING: Two community health centers in Pittsburgh, Pennsylvania. PARTICIPANTS: Two hundred fifty-three patients aged 50 and older in 2001 who visited one of the health centers and completed telephone surveys in 2002 and 2003 after the respective influenza seasons. MEASUREMENTS: Influenza vaccination status, demographic characteristics, and decision-making behavior were self-reported. Vaccination status was identified for three seasons: 2000-2001, 2001-2002, and 2002-2003. A three-level outcome was defined as unvaccinated all 3 years, vaccinated one to two times over 3 years, and vaccinated all 3 years. Factor analysis identified three decision-making behaviors. RESULTS: Predictors of being vaccinated across 3 years included being older, the belief that social forces influence vaccination behavior, and disagreement with the view that vaccine is detrimental. CONCLUSION: National educational efforts should be intensified to dispel the myths about alleged adverse events, including contracting influenza from inactivated influenza vaccine. Physicians should continue to share their personal experiences of treating patients with influenza, including the incidence of hospitalization and death.

Parental perspectives on influenza immunization of children aged 6 to 23 months.

BACKGROUND: For the first time, in 2002, the Advisory Committee on Immunization Practices encouraged the vaccination of healthy children 6 to 23 months against influenza, whenever feasible. Participating inner-city health centers designed interventions to introduce influenza vaccination among this group of children. The study was designed to assess parents' attitudes toward the vaccine. METHODS: Following the 2002-2003 influenza vaccination season, parents were surveyed to identify barriers to and facilitators of influenza vaccination. A low-literacy level, 19-question survey was mailed to parents in three waves, 4 weeks apart. A subset of children had medical record data available to confirm vaccination status. Measures of validity were calculated. This paper focused only on the children whose parent-reported vaccination status was concordant with that reported in medical records (n = 193). Associations of responses to vaccination status were calculated in 2004, using chi-square and logistic regression procedures. RESULTS: Sensitivity was 85.7% and specificity was 66% (kappa = 0.50), assessing the ability of parents to recall receipt or nonreceipt of influenza vaccine. The most important factors related to immunization of healthy infants were perceived doctor's recommendation (odds ratio [OR] = 5.5; 95% confidence interval [CI] = 2.4-12.3; p < 0.001) and belief that getting an influenza shot is a smart idea (OR = 3.5; 95% CI = 1.3-8.9; p < 0.01) for those with medical record-confirmed vaccination status. CONCLUSIONS: A clear message that the doctor recommends influenza vaccination for a child is an important factor for ensuring vaccination, and may foster the idea that vaccination is "smart."

Predictors of pneumococcal polysaccharide vaccination among patients at three inner-city neighborhood health centers.

BACKGROUND: Despite the availability of pneumococcal polysaccharide vaccine (PPV), vaccination rates are modest, and racial disparity in these rates is known to occur. OBJECTIVE: The purpose of this study was to identify determinants of patient-reported receipt of PPV among patients from 3 inner-city health centers that serve large numbers of minority and disadvantaged patients. METHODS: In 2003, a random sample of patients from 3 inner-city health centers was surveyed by computer-assisted telephone interview concerning their vaccination status and their attitudes and beliefs about PPV. The questionnaire was based on the theory of reasoned action, which emphasizes the contributions to behavioral intention of cognitive beliefs (including the likelihood of consequences), the value of those consequences, and normative beliefs. Factor analysis was conducted to examine whether survey items specific to attitudes about PPV would group together; the variance of the components resulting from the factor analysis was expressed in eigenvalues. Logistic regression analyses were conducted to determine which factors, demographic characteristics, and health habits were independently associated with PPV status. RESULTS: Of 674 patients sent introductory letters (13 of whom were ineligible), 325 (49%) completed the interview with usable data. These patients were primarily aged > or = 65 years (52% [168/325]), female (69% [223/325]), and white (57% [174/306]), and had an annual household income < 20,000 dollars (61% [174/287]). Vaccination status or intention to be vaccinated was unknown for 25 persons, reducing the sample to 300. Of these respondents, 59% (178) reported vaccination, 9% (26) intended to be vaccinated within 6 months, and 32% (96) had no intention of being vaccinated. Vaccination rates were 76% (119/157) for responders aged > or = 65 years and 41% (59/143) for responders aged 50 to 64 years (P < 0.001). Logistic regression analyses found 3 variables that were significantly associated with the likelihood of vaccination: age > or = 65 years; frequency of physician visits; and timing of the last complete physical examination. The factor analysis with varimax rotation identified 2 factors that increased the likelihood of reporting ever receiving PPV: attitudes about PPV and social influences (eigenvalue = 2.69), and beliefs about pneumonia risk and vaccine efficacy (eigenvalue = 1.24). When these factors were added to the model, the effects of age and frequency of seeing a physician became nonsignificant. Compared with those having a complete physical examination < 1 year ago, those having an examination 1 to 2 years ago (odds ratio [OR] = 0.16; 95% CI = 0.04-0.69) or > 2 years ago (OR = 0.10; 95% CI = 0.01-0.78) were less likely to be vaccinated. Those agreeing with the attitudes and social influence factor were more likely to be vaccinated (OR = 8.24; 95% CI = 3.97-17.12), as were those agreeing with the pneumonia risk and vaccine efficacy factor (OR = 2.63; 95% CI = 1.20-5.80). CONCLUSIONS: Attitudes about vaccination and a clinician's recommendation are the most powerful predictors of PPV status. Efforts to raise rates of vaccination and reduce racial disparities should emphasize communication of clinicians' recommendations to patients.

What affects influenza vaccination rates among older patients? An analysis from inner-city, suburban, rural, and Veterans Affairs practices.

BACKGROUND: Despite strong evidence of the effectiveness of influenza vaccination, immunization rates have reached a plateau that is below the 2010 national goals. Our objective was to identify facilitators of, and barriers to, vaccination in diverse groups of older patients. METHODS: A survey was conducted in 2000 by computer-assisted telephone interviewing of patients from inner-city health centers, Veterans Affairs (VA) outpatient clinics, rural practices, and suburban practices. The inclusion criteria were age > or =66 years and an office visit after September 30, 1998. RESULTS: Overall, 1007 (73%) interviews were completed among 1383 patients. Influenza vaccination rates were 91% at VA clinics, 79% at rural practices, 79% at suburban practices, and 67% at inner-city health centers. There was substantial variability in vaccination rates among practices, except at the VA. Nearly all persons who were vaccinated reported that their physicians recommended influenza vaccinations, compared with 63% of unvaccinated patients (P <0.001). Thirty-eight percent of unvaccinated patients were concerned that they would get influenza from the vaccine, compared with only 6% of vaccinated persons (P <0.001). Sixty-three percent of those vaccinated, in contrast with 22% of unvaccinated persons, thought that an unvaccinated person would probably contract influenza (P <0.001). CONCLUSION: Older patients need intentional messages from physicians that recommend vaccination. Furthermore, more patient education is needed to counter myths about adverse reactions.

Barriers to pneumococcal and influenza vaccination in older community-dwelling adults (2000-2001).

OBJECTIVES: To identify facilitators of and barriers to vaccination in patients from a range of socioeconomic levels. DESIGN: A survey was conducted in 2001 using computer-assisted telephone interviewing. SETTING: Patients from inner-city health centers and suburban practices were interviewed. PARTICIPANTS: Inclusion criteria were aged 66 and older and an office visit after September 30, 1998. MEASUREMENTS: Self-reported influenza and pneumococcal vaccination status and facilitating conditions, attitudes, social influences, and perceived consequences from the Triandis model were assessed. RESULTS: Overall, 557 interviews were completed with 775 eligible patients (72%). Patients who reported having received pneumococcal vaccine more frequently believed that their physicians recommended the vaccine than did the unvaccinated (97% vs 49%; P=.001). This was also true for influenza vaccine (99% vs 80%; P<.001). More unvaccinated patients than vaccinated patients felt that obtaining either vaccine was more trouble than it is worth (pneumococcal 19% vs 1%; P=.04, influenza 20% vs 1%; P=.004). The vaccinated were more likely to be willing to obtain the influenza and pneumococcal vaccines at the same time (pneumococcal 91% vs 59%; P=.002, influenza 91% vs 55%; P=.014). CONCLUSION: Physicians should take every opportunity to recommend vaccination to their eligible adult patients. Offering influenza and pneumococcal vaccines at the same visit is an acceptable means to ensure that adults are fully vaccinated.

Physician and practice factors related to influenza vaccination among the elderly.

BACKGROUND: Influenza vaccination rates among adults, especially in minority populations, remain below national goals of 90%. This study investigated in diverse settings, facilitators of and barriers to patient influenza vaccination from the physician's perspective. METHODS: Two-stage, stratified, random-cluster sampling was employed to select 71 clinicians from inner-city, rural, suburban, and Veterans Affairs (VA) practices, and a random sample of 925 of their patients aged >/=65 years. Questionnaires and interviews based on the PRECEDE-PROCEED framework assessed clinician factors. Associations among clinician beliefs, practice characteristics, patient beliefs, and self-reported influenza vaccination status were determined. RESULTS: The clinician response rate was 85% (60/71). Several factors of the PRECEDE-PROCEED framework were associated with higher influenza vaccination rates. For instance, patients at practices with express vaccination clinics had higher vaccination rates than at clinics without such immunization programs (87% v 76%, p =0.01). Using multivariate models, influenza vaccination status was related to several patient factors, including plans to receive influenza vaccination next year (p <0.001); belief that those who are not vaccinated will contract influenza (p =0.049); and history of being screened for colon cancer (p =0.023). Influenza vaccination status was also related to several physician factors, including awareness of recommendation to vaccinate asthmatics (p =0.024); agreement with these recommendations (p =0.004); and practice type and setting ("strata"), of which the VA was highest. CONCLUSION: Through proactive office systems and education, physicians may influence patients' intentions to be vaccinated and thereby increase influenza vaccination rates.

Impact of hospital policies on health care workers' influenza vaccination rates.

BACKGROUND: Overall annual influenza vaccination rate has slowly increased among health care workers but still remains below the national goal of 90%. METHODS: To compare hospitals that mandate annual health care worker (HCW) influenza vaccination with and without consequences for noncompliance, a 34-item survey was mailed to an infection control professional in 964 hospitals across the United States in 4 waves. Respondents were grouped by presence of a hospital policy that required annual influenza vaccination of HCWs with and without consequences for noncompliance. Combined with hospital characteristics from the American Hospital Association, data were analyzed using χ(2) or Fisher exact tests for categorical variables and t tests for continuous variables. RESULTS: One hundred fifty hospitals required influenza vaccination, 84 with consequences (wear a mask, termination, education, restriction from patient care duties, unpaid leave) and 66 without consequences for noncompliance. Hospitals whose mandates have consequences for noncompliance included a broader range of personnel, were less likely to allow personal belief exemptions, or to require formal declination. The change in vaccination rates in hospitals with mandates with consequences (19.5%) was nearly double that of the hospitals with mandates without consequences (11%; P=.002). Presence of a state law regulating HCW influenza vaccination was associated with an increase in rates for mandates with consequences nearly 3 times the increase for mandates without consequences. CONCLUSION: Hospital mandates for HCW influenza vaccination with consequences for noncompliance are associated with larger increases in HCW influenza vaccination rates than mandates without such consequences.

Cost-effectiveness of pneumococcal conjugate vaccination in immunocompromised adults.

OBJECTIVE: Pneumococcal disease is a significant problem in immunocompromised persons, particularly in HIV-infected individuals. The CDC recently updated pneumococcal vaccination recommendations for immunocompromised adults, adding the 13-valent pneumococcal conjugate vaccine (PCV13) to the previously recommended 23-valent pneumococcal polysaccharide vaccine (PPSV23). This analysis estimates the cost-effectiveness of pneumococcal vaccination strategies in HIV-infected individuals and in the broader immunocompromised adult group. DESIGN: Markov model-based cost-effectiveness analysis. METHODS: The model considered immunocompromised persons aged 19-64 years and accounted for childhood PCV13 herd immunity; in a separate analysis, an HIV-infected subgroup was considered. PCV13 effectiveness was estimated by an expert panel; PPSV23 protection was modeled relative to PCV13 effectiveness. We assumed that both vaccines prevented invasive pneumococcal disease, but only PCV13 prevented nonbacteremic pneumonia. RESULTS: In all immunocompromised individuals, a single PCV13 cost $70,937 per quality adjusted life year (QALY) gained compared to no vaccination; current recommendations cost $136,724/QALY. In HIV patients, with a longer life expectancy (22.5 years), current recommendations cost $89,391/QALY compared to a single PCV13. Results were sensitive to variation of life expectancy and vaccine effectiveness. The prior recommendation was not favored in any scenario. CONCLUSIONS: One dose of PCV13 is more cost-effective for immunocompromised individuals than previous vaccination recommendations and may be more economically reasonable than current recommendations, depending on life expectancy and vaccine effectiveness in the immunocompromised.

Modeling of cost effectiveness of pneumococcal conjugate vaccination strategies in U.S. older adults.

BACKGROUND: The 13-valent pneumococcal conjugate vaccine (PCV13) is approved by the U.S. Food and Drug Administration for adults, but its role in older adults is unclear. PURPOSE: To compare PCV13 strategies to currently recommended vaccination strategies in adults aged ≥65 years. METHODS: Using a Markov model, the cost effectiveness of PCV13 and the 23-valent pneumococcal polysaccharide vaccine (PPSV23), alone or in combination, was estimated, in adults aged either 65 years or 75 years. No prior vaccination, prior vaccination, and vaccine hyporesponsiveness scenarios were examined. Pneumococcal disease rates, indirect childhood PCV13 effects, and costs were estimated using CDC Active Bacterial Core surveillance data and U.S. national databases. An expert panel estimated vaccine-related protection. A societal perspective was taken and outcomes were discounted 3% per year. RESULTS: In those aged 65 years, single-dose PCV13 cost $11,300 per quality-adjusted life-year (QALY) gained compared to no vaccination; at ages 65 and 80 years, PCV13 cost $83,000/QALY. In those aged 75 years, single-dose PCV13 cost $62,800/QALY gained. PPSV23 cost more and was less effective than PCV13. Results were sensitive to varying vaccine effectiveness and indirect effect estimates. In hyporesponsiveness scenarios, cost-effectiveness ratios increased by 37%-78% for single-dose strategies and 29%-35% for multiple-dose strategies. CONCLUSIONS: Single-dose PCV13 strategies are likely to be economically reasonable in older adults.

Hospital policies, state laws, and healthcare worker influenza vaccination rates.

This study used hierarchical linear modeling to determine the relative contribution of hospital policies and state laws to healthcare worker (HCW) influenza vaccination rates. Hospital mandates with consequences for noncompliance and race were associated with 3%-12% increases in HCW vaccination; state laws were not significantly related to vaccination rates.

Evaluation of a toolkit to introduce standing orders for influenza and pneumococcal vaccination in adults: a multimodal pilot project.

BACKGROUND: Immunization of adults with influenza vaccine and pneumococcal polysaccharide vaccine remains lower than recommended levels. Standing order programs (SOPs) in which non-physician medical personnel are permitted to assess an adult patient's immunization status and administer vaccines without an individual physician order are a proven method of increasing adult vaccinations, yet they are used by less than one half of primary care physicians caring for adults. METHODS: Following a national survey of primary care physicians about barriers to SOPs for adult immunizations, a SOP toolkit was developed. After review by a panel of experts, the toolkit was pilot tested in three primary care practices in a health care network with the same electronic medical record (EMR) system and low adult vaccination rates. Practice staffs were trained in the use of SOPs and the toolkit at a group meeting. This study was designed to pilot-test and evaluate the toolkit with the express intention of improving it. Three methods were used to evaluate the toolkit: (1) direct observation and interviews of each practice's staff; (2) surveys of each practice's staff; and (3) influenza and pneumococcal polysaccharide vaccine (PPV) vaccination rates. RESULTS: The staffs at all sites were equally likely to find the presentations and toolkit useful and did not differ in their knowledge of using SOPs for vaccination. They expressed a common set of barriers to implementing SOPs despite using the toolkit, and provided ideas for improving implementation. One site viewed SOPs in general in a more negative light and expressed that SOPs unfairly increased their workload. Vaccination rates in this site did not differ from those of the control site. CONCLUSION: The evaluation suggested that the SOP toolkit should be expanded to include additional strategies to improve its applicability and effectiveness.