Donald B. Middleton

Economic evaluation of standing order programs for pneumococcal vaccination of hospitalized elderly patients.

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

Increasing pneumococcal vaccination rates among hospitalized patients.

10,000 per quality-adjusted life-year gained, with program costs (pharmacy-based SOPs cost

Overcoming barriers to establishing an inpatient vaccination program for pneumococcus using standing orders.

4.16 per patient screened, and nursing-based SOPs cost

Performance on the American Board of Family Medicine Certification Examination by Country of Medical Training

4.60 per patient screened) and vaccine costs (

Using the 4 Pillars™ Practice Transformation Program to increase adult Tdap immunization in a randomized controlled cluster trial

18.33 per dose) partially offset by potential savings from cases of invasive pneumococcal disease avoided (

Pass Rates on the American Board of Family Medicine Certification Exam by Residency Location and Size

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.

The Vaccine Misinformation Landscape in Family Medicine

OBJECTIVE To increase the proportion of inpatients vaccinated against pneumococcal infection. DESIGN Pre- and post-intervention study. SETTING University medical center-affiliated, suburban community teaching hospital. PATIENTS Unvaccinated inpatients 65 years and older and those 2 to 64 years old who had chronic medical conditions predisposing them to invasive pneumococcal infection. INTERVENTION The nursing staff screened newly admitted patients for eligibility based on age, diagnosis, or medications from a computer-generated admissions list and placed a pre-printed order form for the pneumococcal polysaccharide vaccine (PPV) on the charts of eligible patients. Following the physicians order, the nursing staff administered the PPV and recorded it Ongoing quality improvements including admission vaccination screening and computer-based record keeping were initiated to identify unvaccinated eligible patients and track vaccination status. RESULTS Efforts resulted in rates of in-hospital vaccination ranging from 3.1% to 7.9% (mean, 5.2% +/- 1.7% [standard deviation]) and significant improvements in the assessment of previous vaccination status, reaching 54% of eligible patients after 1 year. Ascertainment of a previous vaccination increased significantly following the initiation of the use of admission forms that specifically assessed vaccination status and a system to permanently record vaccination status in an electronic medical record (P < .05). CONCLUSION Concerted efforts using electronic medical records significantly improved the assessment and documentation of inpatient vaccination status. Greater improvement of the rates of in-hospital vaccination will require healthcare system-wide efforts such as a standing order policy for vaccinating all eligible patients. Standing orders for inpatient immunization supported by effective assessment and tracking systems have the potential to raise vaccination rates to the goals of Healthy People 2010.

Keeping Up-to-Date with Immunization Practices

OBJECTIVES To identify and classify barriers to establishing a standing orders program (SOP) for adult pneumococcal vaccination in acute care inpatient facilities and to provide recommendations for overcoming these roadblocks. Vaccination rates in hospitals with SOPs are generally higher than those in hospitals that require individual physician orders. The array of solutions drawn from our experience in different hospital settings should permit many types of facilities to anticipate and overcome barriers, allowing a smoother transition from initiation to successful implementation of an inpatient pneumococcal vaccination SOP. DESIGN Descriptive study of barriers and solutions encountered during implementation of a pneumococcal vaccination SOP in three hospitals of the University of Pittsburgh Medical Center Health System (UPMC) and in the scientific literature. SETTING As of 2004, two UPMC tertiary-care hospitals and one UPMC community hospital had incorporated SOPs into existing physician order-driven programs for inpatient vaccination with pneumococcal polysaccharide vaccine. RESULTS Barriers were identified at each step of implementation and categorized as patient related, provider related, or institutional. Based on a process of continual review and revision of our programs in response to encountered barriers, steps were taken to overcome these impediments. CONCLUSIONS A strong commitment by key individuals in the facilitys administration including a physician champion; ongoing, persistent efforts to educate and train staff; and close monitoring of the vaccination rate were essential for successful implementation of a SOP for pneumococcal vaccination of eligible inpatients. Legal statutes and evaluations of external hospital-rating associations regarding the effectiveness of the vaccination program were major motivating factors in its success.

Dissemination and implementation of the ICAMP

Background: Performance on the American Board of Family Medicine (ABFM) Certification and Recertification Examinations by country of medical school training has not been examined. Based on internal medicine patterns, we hypothesize that examinees trained in the United States and Canada would outperform examinees trained in other countries. Methods: In this retrospective cohort study from 2004 to 2011, data on the ABFM examinations were obtained from the ABFM. Fisher exact and χ2 tests were performed across years based on the country of examinee training. Simple linear regression was performed to evaluate pass rates over time. All statistics were performed using an α = 0.05. Results: The overall pass rate over the study period was 84.4% (74,821 of 88,680). The pass rate for US medical graduates (USMGs) was 88.3% (60,328 of 68,332). The pass rate for Canadian medical graduates (CMGs) was 93.8% (872 of 930). The pass rate for non-Canadian foreign medical gradates (NC-FMGs) was 70.1% (13,621 of 19,418). CMGs had a higher pass rate than USMGs (P < .001) and NC-FMGs (P < .001). Simple linear regression showed significant decreasing trends over time for all examinees (P = .02), for USMGs (P = .02), and for CMGs (P = .02). Conclusions: USMGs and CMGs outperform NC-FMGs on the ABFM certification and recertification examinations. These findings may alter acceptance patterns for Family Medicine residency programs.

Does influenza vaccination status change physician ordering patterns for respiratory viral panels? Inspection for selection bias

INTRODUCTION National adult Tdap vaccination rates are low, reinforcing the need to increase vaccination efforts in primary care offices. The 4 Pillars™ Practice Transformation Program is an evidence-based, step-by-step guide to improving primary care adult vaccination with an online implementation tracking dashboard. This study tested the effectiveness of an intervention to increase adult Tdap vaccination that included the 4 Pillars™ Program, provider education, and one-on-one coaching of practice-based immunization champions. METHODS 25 primary care practices participated in a randomized controlled cluster trial (RCCT) in Year 1 (6/1/2013-5/31/2014) and a pre-post study in Year 2 (6/1/2014-1/31/2015). Baseline year was 6/1/2012-5/31/2013, with data analyzed in 2016. Demographic and vaccination data were derived from de-identified electronic medical record (EMR) extractions. The primary outcomes were vaccination rates and percentage point (PP) changes/year. RESULTS The cohort consisted of 70,549 patients ⩾18years who were seen in the practices ⩾1 time each year, with a baseline mean age=55years; 35% were men; 56% were non-white; 35% were Hispanic and 20% were on Medicare. Baseline vaccination rate averaged 35%. In the Year 1 RCCT, cumulative Tdap vaccination increased significantly in both intervention and control groups; in both cities, the percentage point increases in the intervention groups (7.7 PP in Pittsburgh and 9.9 PP in Houston) were significantly higher (P<0.001) than in the control groups (6.4 PP in Pittsburgh and 7.6 PP in Houston). In the Year 2 pre-post study, in both cities, active intervention groups increased rates significantly more (6.2 PP for both) than maintenance groups (2.2 PP in Pittsburgh and 4.1 PP in Houston; P<0.001). CONCLUSIONS An intervention that includes the 4 Pillars™ Practice Transformation Program, staff education and coaching is effective for increasing adult Tdap immunization rates within primary care practices. Clinical Trial Registry Name/Number: NCT01868334.