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Show maintenance organization in Minnesota in 1990-1993. Influenza immunization rates ranged from 45-58%; vaccination was associated with decreased hospitalization rates (by 48-57%, p=0.002) for pneumonia and influenza, and statistically significant reductions in mortality (by 39-54%, p=0.001). They calculated direct yearly savings of $117 per person vaccinated, a cumulative savings of $5 million. Sisk et al. (1997) performed a base case analysis from three geographic areas in the U.S. By extrapolation, they report that if the 23 million unvaccinated elderly persons in 1993 nationwide had been vaccinated against invasive pneumococcal disease, 78,000 years of healthy life would have been gained and $194 million in health care costs would have been saved. It is well documented that these vaccines are underutilized. A Healthy People 2000 goal is to increase pneumococcal and influenza vaccination levels to at least 60% for non-institutionalized high-risk persons including those aged >65 years (PHS, 1991). Nationally, progress has been made toward this goal; immunization levels have increased among adults > 65 years (52% influenza, 28% pneumococcal pneumonia) (PHS, 1995). Only 42% of persons in Utah > 65 years of age report ever receiving a pneumonia shot; 70% report an influenza shot during the previous 12 months (CDC [Behavioral Risk Factor Surveillance Survey coordinators], October 1997). The Advisory Committee on Immunization Practices recommends that the pneumococcal pneumonia vaccine be given during the inpatient stay to eligible patients, but this occurred less than 1% of the time in 12 western states in 1994 (random sample of 5048 hospitalizations for Medicare patients > 65 years with principal diagnosis of pneumonia, 6.2% were in Utah). In addition, medical record review for this study revealed that previous vaccinations were documented in hospital admission histories only 4.7% of the time (CDC [Houck, Lowery, Prela], October 1997). Reasons for underuse of these vaccines in any setting range from misunderstanding of their effectiveness (although studies show that doubts about effectiveness are common even among vaccinees), contraindications, and side-effects by patients and physicians (physicians see a barrier to immunizing inpatients because vaccine effects such as fever could extend the length of stay). Patients= fear of side-effects was the biggest barrier cited in multiple studies (Fieback and Beckett, 1994). A physician recommendation to be vaccinated has been shown to be an important factor in being vaccinated, but provision of preventive health interventions by physicians has been shown to be variable and sub-optimal (Cohen, 1994). Having a scheduled appointment with a physician during the fall season has been shown to be a positive determinant of influenza vaccinations (Fieback and Beckett, 1994). Lack of awareness of recommendations, vaccine delivery and availability problems, and inadequate financing mechanisms to support adult immunization delivery are additional barriers (Fedson, 1994). Medicare-aged Inpatients are at High Risk for Subsequent Pneumonia Part A Medicare data has unique patient identifiers to enable patient-specific analysis over time. While immunization for pneumococcal pneumonia and influenza is recommended for all Medicare-aged persons, persons > 65 years of age who have been hospitalized are an especially high risk group for re-hospitalization for pneumonia. Medicare inpatients (any reason for admission) are roughly three times more likely to be re-hospitalized for pneumonia in the following year than Medicare beneficiaries not hospitalized. Utah Medicare patients initially hospitalized for pneumonia (1993-96), experienced a seven times greater risk of readmission for pneumonia within one year compared to Medicare beneficiaries who were not hospitalized (see Table 1). Inpatient Admission-Missed Opportunity for Vaccination In Manitoba, analysis of claims data from 1982-83 demonstrated that among those >65 years of age hospitalized with influenza-associated diagnoses, 39-46% had been hospitalized during the previous vaccination season; 62-67% of those who died had been hospitalized within the previous vaccination season (Fedson, Wajda, Nicol, and Roos, 1992). A hospitalization should thus be considered an opportunity for vaccination and pneumonia prevention. Similarly, of Utah Medicare patients hospitalized for pneumonia during the influenza season (January through April, 1994-97), over one-third had been hospitalized during the previous year, almost half of them during the influenza vaccine availability period. These represent missed opportunities to prevent two of the most important etiologies for elderly pneumonia hospitalizations (see Table 2). 59 |