AARP Public Policy Institute INSIGHT on the Issues Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries This Insight on the Issues discusses adult immunization recommendations for flu and pneumonia and current Medicare immunization coverage policies. It also presents data on immunization disparities, discusses factors that may contribute to the disparities, and highlights federal and state initiatives to address them. Introduction with flu and pneumonia because both diseases often exacerbate underlying Influenza (commonly called flu) and chronic conditions, such as heart or lung pneumonia are both vaccine-preventable disease, asthma, and diabetes.6 diseases. Yet together they represented the eighth leading cause of death in the The Advisory Committee on United States and the sixth leading cause Immunization Practices (ACIP) is of death among persons age 65 and older an expert panel selected by the in 2005.1 Influenza is responsible for secretary of the U.S. Department of approximately 36,000 deaths and more Health and Human Services to advise than 200,000 hospitalizations each year the nation on how to reduce vaccine- in the U.S. More than 90 percent of these preventable diseases. The ACIP, deaths occur among those ages 65 and which develops standards for routine older.2 Pneumococcal pneumonia affects vaccine administration, including about 33,000 persons a year, resulting in dosage, periodicity schedules, and 5,000 deaths. Similar to flu, most of the applicable contraindications for deaths caused by pneumonia occur pediatric and adult populations,7 among those ages 65 and older.3 recommends the following: Flu and pneumonia immunization rates An annual influenza vaccine for among all older adults are significantly adults age 50 and older and for all below the Healthy People 2010 goals of persons who live in long-term care 90 percent for each vaccine.4 However, facilities, and immunization rates among African Americans and Hispanics are A one-time vaccination for substantially below those of their white pneumococcal pneumonia for all counterparts.5 adults age 65 and older. Adult Immunization The Medicare Program covers Recommendations and pneumococcal and influenza vaccines Medicare Coverage for persons age 65 and older in accordance with ACIP The Medicare population is especially recommendations. Medicare pays both susceptible to complications associated the cost of the vaccines and their Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries administration by participating Americans and 45 percent of older providers. Once five years have elapsed Hispanics reported having received the since the initial pneumococcal vaccine, a flu vaccine (Figure 1). Influenza booster vaccine is covered for persons in immunization disparities persist, even high-risk categories.8 after controlling for other factors such as socioeconomic status and the presence There is no coinsurance or copayment of risk factors for influenza.10 associated with either vaccine, and beneficiaries are not required to meet a The gap is even wider for pneumonia deductible to receive them.9 immunization rates, with only 36 percent of African Americans and 33 percent of Disparities in Immunization Rates Hispanics reporting having been vaccinated among Medicare Beneficiaries in 2006, compared with 62 percent of their white counterparts (Figure 2). Despite Medicare’s coverage of influenza and pneumonia vaccines at no The social cost of immunization out-of-pocket cost to beneficiaries, the disparities is preventable hospitalizations number of people who are immunized is and deaths. A 2007 study estimated that less than optimal, with even lower rates if flu immunization rates were equal for noted among African Americans and all races, 1,880 minority deaths could be Hispanics. prevented every year, saving more than 33,000 minority life years.11 Moreover, In 2006, 67 percent of white adults age if all racial groups achieved the national 65 and older reported receiving the Healthy People 2010 goal of 90 percent influenza vaccine. During the same flu vaccination, 15,590 elderly deaths period, 47 percent of older African could be prevented annually.12 Figure 1. Figure 2. Influenza Immunization Rates for Pneumococcal Immunization Rates for Population Age 65+, Population Age 65+, by Race/Ethnicity, 1989-2006 by Race/Ethnicity, 1989-2006 80 80 70 70 60 60 50 50 Percent Percent 40 40 30 30 20 20 10 10 0 0 89 91 93 95 97 99 01 03 04 05 06 19 19 19 19 19 19 20 20 20 20 20 Hispanic or Lat ino Whit e only Hispanic or Lat ino Whit e only Black or Af rican Amer ican only Black or Af rican American only Source: National Healt h Int erview Survey, 1989-2004 Source: National Health Interview Survey, 1989-2004 2 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries Factors Associated with Racial in the Mississippi delta region. Although and Ethnic Immunization the projects and targeted population Disparities among Medicare varied among the project sites, all Beneficiaries projects shared three underlying principles: Researchers have associated the Develop local buy-in to the project following factors with low flu and design; pneumococcal pneumonia immunization rates among African Americans and Engage stakeholders (persons age 65 Hispanics: and older); and Consumer lack of awareness about Use evidence-based interventions the need for the vaccinations;13 with providers and in the community. 21 Consumer fear that the vaccines will cause severe illness;14 Each READII site developed community plans, conducted communications Few consumer-initiated visits to research to determine which messages providers to receive the vaccines;15 resonated best with older African American and Hispanic community Provider underestimation of the members, and conducted local safety and efficacy of the vaccines;16 community events. Strategies aimed at providers included education about Provider lack of familiarity with standing orders (e.g., a notation in a age-based immunization patient’s medical record that prompts the recommendations;17 provider to automatically provide a flu or pneumonia vaccine to a patient), Provider failure to recommend patient reminders and recalls, and age-appropriate immunizations to provider reminders.22 older adults;18 and The outcomes of READII were mixed, Provider failure to institute standing- but provide important evidence and order programs despite ACIP strategies for future efforts. Overall, flu recommendations to use them.19 and pneumonia vaccination disparities Federal Initiatives to Address decreased among all the project sites, Immunization Disparities though the overall change was not statistically significant.23 The most In 2002, the Centers for Disease Control successful efforts targeted providers.24 and Prevention (CDC), in partnership For example, outreach workers in with other federal agencies, launched a Rochester clinics used a patient three-year demonstration project to database to monitor seniors, provided address racial and ethnic disparities in direct reminders to patients by telephone immunization rates among African and mail, and alerted providers to American and Hispanic Medicare unvaccinated patients with chart beneficiaries.20 The project, called the reminders and prompts.25 The Racial and Ethnic Adult Disparities in procedures, combined with broader Immunization Initiative (or READII, outreach efforts, resulted in 80 percent pronounced “ready”) was launched in of seniors receiving the pneumonia five sites—Chicago, Illinois; Rochester, vaccine over the two-year period and New York; San Antonio, Texas; substantial increases in flu vaccination Milwaukee, Wisconsin; and 19 counties across racial groups.26 It should be noted 3 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries that Rochester’s successful interventions State Strategies to Address depended on outside funding, making Immunization Disparities its outcomes difficult to replicate in areas with fewer available resources.27 States use a variety of strategies to In Mississippi, making offers of increase immunization rates among older vaccination a standard part of health adults, including Medicare beneficiaries. clinic visits raised immunization rates Some of these activities are described for all racial groups.28 Collaboration below. with local groups—private foundations, local clinics and community health Illinois centers, media outlets, faith-based The Chicago Department of Public organizations, professional organizations, Health (CDPH) partners with and AARP—varied among READII sites community groups to provide increased depending on the local environment and access to immunizations in high-risk helped lay a foundation for future communities. As one of the READII community health interventions.29 project sites, Chicago developed community collaborations that have Another federal effort to increase lasted beyond the conclusion of the CDC immunization rates among older persons study. During flu season, the CDPH runs was focused on residents of long-term eight weekend faith-based vaccine care facilities. The Centers for Medicare clinics and promotes vaccine use in and Medicaid Services (CMS) issued target communities.34 In the 2007–2008 final rules on October 7, 2005, requiring flu season, about 16,000 vaccines were Medicare and Medicaid long-term care administered, with the greatest success facilities to offer flu and pneumococcal reported in churches in the Hispanic vaccines to their residents. Long-term community, though use in African care facilities must document refusals American faith communities is and indicate that the resident or his or increasing.35 Because some of the her legal representative received elderly are unable to come to CDPH appropriate education and consultation. weekend clinics, the city supplied Although African Americans and vaccine to providers in the communities Hispanics are not targeted in the rule, where the READII project operated.36 those living in nursing homes can benefit Statewide, long-term care facilities are from this policy.30 required to respond to a survey of Together with its partners,31 CMS immunization practices. The most recent conducted a cross-country bus tour, survey found that 70.1 percent of titled “A Healthier U.S. Starts Here,” residents received a flu vaccine in the during spring and summer of 2007 to 2007–2008 season and 48.8 percent had promote awareness of Medicare’s received a pneumonia vaccine in the prevention benefits, including flu and previous five years.37 pneumococcal immunizations. Although the tour did not specifically address Minnesota immunization disparities, African In 2001, the Minnesota legislature created American and Hispanic beneficiaries the 10-year, statewide Eliminating were among the targeted groups.32 The Health Disparities Initiative (EHDI) to tour reached the 48 continental states address health disparities in the state. with information about prevention and The goal of the initiative is to fund a wellness.33 variety of projects that promote culturally appropriate, community-based public health programs.38 4 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries For example, one initiative that focuses motivate consumers to seek on adult immunization disparities is a immunizations; and project, called “There Is a Balm,” which targets faith-based communities to raise Working with media outlets to awareness among African Americans design and promote culturally about the need and requirements for appropriate messages. 42 adult immunization, and encourages individuals to take charge of their health. Texas The project partners with area clinics to In 2005, the Texas Legislature passed provide free vaccines and reaches about legislation (Senate Bill 1330) seeking 20 churches around the Twin Cities to increase availability of flu and metro area. At present, insufficient funds pneumonia vaccines to the elderly.43 The have made it impossible to fully study law requires hospitals, dialysis centers, the outcomes of EHDI efforts to increase and doctors’ offices to provide vaccine use.39 information about vaccination to elderly patients and to directly offer flu and New York pneumonia vaccines to patients admitted The New York City Department of for more than 24 hours.44 Hospital Health and Mental Hygiene’s Bureau licensing rules in Texas now include this of Immunization (the Bureau) uses requirement, and the obligation seems to data from the annual New York City have been met without incident.45 Community Health Survey (CHS) to obtain neighborhood and citywide Linking Vaccination with Voting estimates of immunization rates among targeted populations.40 According to Several states and nonprofit 2006 CHS data, 46.7 percent of African organizations have worked with local Americans and 54.2 percent of Hispanics election authorities to set up vaccine age 65 and older reported received the clinics at or near polling places.46 influenza vaccination within the past Pairing vaccination with voting is year, compared to 61.6 percent of their an innovative strategy and has been white counterparts.41 In the same year, shown to be effective. The elderly are 42.9 percent of African Americans and consistent voters, making polling places 34.4 percent of Hispanics age 65 and good sites for reaching high-priority older reported having ever received a individuals. Furthermore, elections pneumococcus vaccine, compared with occur during the recommended flu 54.3 percent of their white counterparts. immunization season. The influenza vaccine can be administered quickly Bureau activities to address and, since no follow-up is needed, immunization disparities include the election-day clinics can supplement the following: efforts of primary care providers. Most important, vaccination efforts carried Working with medical providers out at the local level can better target to address provider behavior and outreach strategies designed to reach strengthen their actions to immunize individuals within those communities. their patients; Several projects have shown impressive Developing partnerships with a success. A 19-state project in 2006, variety of community-based funded by the Robert Wood Johnson organizations to educate and Foundation through the Sickness Prevention Achieved through Regional 5 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries Collaboration (SPARC), delivered in vaccine information and vaccine vaccines at 127 election sites in 25 administration through the American cities.47,48 More than 80 percent of the Pharmacists Association Immunization adults who were immunized through Delivery Program.54 the Vote & Vax project were in CDC- defined “priority groups,” which include For nearly a decade, the American persons over 50, and 28 percent of those College of Physicians-American Society immunized reported they would not of Internal Medicine has supported have received a vaccine but for the pharmacists as immunizers.55 Further, polling place clinics.49 Unlike research has demonstrated a public interventions targeted to elderly and health benefit: One study found that minority populations, Election Day persons age 65 and older who lived in clinics cannot limit their appeal to states where pharmacists were allowed subsets of the general population (e.g., to provide vaccines had significantly the elderly or minorities) while higher flu vaccine rates than those who maintaining their political neutrality. lived where pharmacists’ scope of Charges that vaccination efforts are practice did not include vaccination.56 attempts to “get out the vote” and bring Another important benefit is economic specific demographic groups to the polls savings: Research from 2008 resulted in the closure of one clinic in demonstrated that vaccination in a 2006.50 A larger effort is under way to pharmacy is less costly than in a organize immunization clinics at polling scheduled doctor’s office visit or other places for the 2008 presidential election, “traditional setting.”57 with a goal of 1,000 sites.51 Making Providers Accountable Pharmacists as Providers Health care providers are an important CDC has urged increasing access to part of the vaccination challenge. vaccination services “in nontraditional Providers are trusted and respected by settings as another strategy in pursuit many patients and are often uniquely of national vaccination coverage able to identify and educate at-risk objectives.”52 All states but Maine have patients about the benefits of prevention enacted laws permitting pharmacists to and allay concerns about risks of administer certain vaccines. Many states vaccinations. For many patients, the also permit other licensed health care advice of a health care provider may professionals to provide immunizations. carry more weight than public health The most recent law was enacted in literature and outreach campaigns. September 2008 in New York, the scope of which is similar to those on the books In some types of health care organizations, providers may realize the cost savings of in many other states: licensed preventions. Influenza and pharmacists may administer flu and pneumococcus immunization can pneumococcal vaccines to adults.53 prevent costly treatment of these In-store mass flu immunization clinics diseases, and providers may be able to held each fall have become common, realize cost savings by vaccinating more but some community-based pharmacists of their patients. are trained and prepared to offer other vaccines year-round. Since 1996, In recent years, CMS (like other large more than 40,000 pharmacists and purchasers) has promoted accountability pharmacy students have been trained of its contracting providers by publishing reports that compare 6 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries performance on various evidence-based administered annually, and the ad hoc measures, including immunization rates nature of many public health vaccination for flu and pneumonia for older adults efforts undermines the effectiveness enrolled in Medicare. Affording of prevention. consumers access to comparative information, helps them choose high- The key challenge remains reaching the performing clinicians, facilities, and target population: READII showed that health plans. In addition, there is offering vaccines directly and making evidence that health plans that publicly patient and provider reminders routine report quality measures have higher dramatically improved vaccine usage in quality than plans that do not. Thus, minority populations.60 Nevertheless, even if consumers do not use quality these strategies require funding and measures in their decision making, personnel from a public health system providers do focus on areas for which and primary care community that often they are held publicly accountable. face competing priorities for financial and human resources.61 Medicare currently requires health plans participating in the Medicare Advantage Conclusion program to collect and report data on flu and pneumococcal vaccination rates. Although the Medicare program pays These results are published on for influenza and pneumococcal www.Medicare.gov. In addition, CMS’s vaccinations for all beneficiaries, racial Physician Quality Reporting Initiative and ethnic disparities persist among (PQRI) includes flu and pneumonia African Americans and Hispanics. A measures and offers financial incentives 2006 study showed that, when vaccines to physicians who report them. are offered to all persons 65 years or However, PQRI measures are not yet older in a clinical setting in the same publicly reported. manner, the single most important factor determining flu vaccination is past Some plans go beyond public reporting receipt of flu vaccine.62 In the 2006 to base payment to providers on their study, age, gender, education, and race performance. Providers in these plans were all inconsequential if a person have the opportunity to receive a received a vaccine the prior year. This financial bonus if they perform well on is encouraging in the face of disparities quality measures; for example if they because it implies that vaccination have high rates of vaccinations. efforts will become easier to sustain as they progress and people’s habits Challenges change. It also emphasizes a role for providers in promoting vaccine use. Despite the success of small-scale, local Evidence from local-level studies initiatives, sustainability and broader support the prediction of Douglas reach remains a concern. Programs that Shenson, the director of SPARC: “If operate locally and depend heavily on preventive services are placed within local resources, funding, and staffing easy reach across the community, and from year to year may not last. Election if health professionals provide Day clinics have cited difficulty straightforward messages about their obtaining vaccine as a continuing effectiveness, more Americans will take challenge, as well as securing long-term advantage of their availability,” to the funding commitments from public health betterment of the population as a agencies that do not prioritize adult whole.63 immunization.58,59 Flu vaccines must be 7 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries There are promising strategies to promote influenza and pneumococcal 2003,” Morbidity and Mortality Weekly Review, 53(43), November 5, 2004. immunization among the general 7 population, as well as efforts targeted at Centers for Disease Control and Prevention, African Americans and Hispanics. The National Immunization Program, Advisory Committee on Immunization Practices, challenge is twofold: educating patients http://www.cdc.gov/nip/acip/. about the benefits of vaccination so they 8 can engage in responsible disease Persons who receive a pneumococcal vaccine before age 65 should receive another dose after prevention and aligning providers and they turn age 65 and five years have elapsed health systems to prioritize adult since their first dose. Persons with the following vaccination. The success of targeted conditions should receive a booster vaccine: short-term efforts depends on functional or anatomic asplenia (e.g., sickle cell broader sustained commitment to disease, splenectomy), human immunodeficiency vaccination to increase immunization virus (HIV) infection, leukemia, lymphoma, Hodgkin’s disease, multiple myeloma, among all populations. generalized malignancy, chronic renal failure, nephritic syndrome, or other conditions associated with immunosuppression, such as 1 organ or bone marrow transplantation, and National Center for Health Statistics, Health, those receiving immunosuppressive United States, 2007, with Chartbook on Trends chemotherapy. Centers for Disease Control and in the Health of Americans (Hyattsville, MD: Prevention, “Recommended Adult Immunization U.S. Department of Health and Human Services, Schedule—United States, October 2006– 2007). September 2007,” Mortality and Morbidity Weekly 2 Report, 55(40), Q1–Q4, October 13, 2006, Partnership for Prevention, Strengthening Adult Immunization: A Call to Action (Washington, http://www.cdc.gov/mmwr/preview/mmwrhtml/ DC: Medicare and Medicaid Programs); mm5540-Immunizationa1.htm; Centers for “Condition of Participation: Immunization Medicare and Medicaid Services, Dallas Standard for Long Term Care Facilities,” Regional Office, Immunizers’ Question and Federal Register, 70(194), Friday, October 7, Answer Guide to Medicare Coverage of 2005/Rules and Regulations. Influenza and Pneumococcal Vaccinations: 3 Steps to Promoting Wellness Adult Partnership for Prevention, op. cit. Immunizations (Dallas, TX: October 2006). 4 Healthy People 2010 is a set of health 9 Ibid. objectives for the nation to achieve over the first 10 decade of the new century. Healthy People 2010 Herbert, P.L., et al., “The Causes of Racial and was developed through a broad consultation Ethnic Differences in Influenza Vaccination process, built on the best scientific knowledge, Rates among Elderly Medicare Beneficiaries,” and designed to measure programs over time, Health Services Research 40(2), April 2006. U.S. Department of Health and Human Services, 11 Fiscella, K., et al, “Impact of influenza Office of Disease Prevention and Health vaccination disparities on elderly mortality in the Promotion, Healthy People, accessed at United States,” Preventive Medicine, 45: 83–87, http://www.healthypeople.gov/About/ 2007. A “minority life year” refers to a year of whatis.htm. life lived by minority persons across the 5 population. Thus, when Fiscella et al. estimate Supra, note 5. 6 that eliminating annual flu vaccine disparities Nichol, Kristin, et al., “Benefits of Influenza over age 65 would save 33,090 minority life Vaccination for Low-Intermediate-, and High-Risk years, they mean that 33,090 years of life would Senior Citizens,” Archives of Internal Medicine, be gained by minority populations as a whole. 158: 1769–1776, September 14, 1998; Centers for 12 Disease Control and Prevention, “Influenza and Ibid. Healthy People 2010 is a Department of Pneumococcal Vaccination Coverage among Health and Human Services set of goals seeking Persons Age ≥65 Years and Persons Aged 18-64 to raise longevity and health quality while Years with Diabetes or Asthma—United States, eliminating disparities in the U.S. population. The program goals include 28 focus areas, 8 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries 24 including raising influenza and pneumococcus Ibid. immunization rates for the elderly to 25 90 percent. For more information, see Ibid. 26 http://www.healthypeople.gov Ibid. The pneumonia vaccination rates are 13 remarkably consistent, with 79 percent of The Council of State Governments, “Protecting Our Communities: Programs to African American and white seniors and 78 Reduce Adult Immunization Disparities,” percent of Hispanic seniors receiving vaccine. The results for influenza are less clear because Healthy States Brief 1(8), August 2006; Winston, C., et al., “Factors Associated with Vaccination of the 2004 vaccine shortage. In the 2003–2004 of Medicare Beneficiaries in Five U.S. flu season, 64 percent of patients in the intervention group (60 percent of African Americans, Communities: Results from the Racial and Ethnic Adult Disparities in Immunization 68 percent of whites) were vaccinated compared Initiative Survey, 2003,” Journal of the to 22 percent in the control group (25 percent of African Americans, 10 percent of whites). In American Geriatric Society 54: 303–310, 2006. 2004–2005, the year of the shortage, late-season 14 Centers for Disease Control and Prevention, vaccination resulted in 62 percent of African op. cit., note 6; Winston, C., et al., “Factors Americans and 71 percent of White seniors being Associated with Vaccination of Medicare vaccinated. Beneficiaries in Five U.S. Communities: Results 27 from the Racial and Ethnic Adult Disparities in Ibid. 28 Immunization Initiative Survey, 2003,” Journal Ibid. of the American Geriatric Society, 54: 303– 29 310, 2006. Ibid. 30 15 Winston, 2006, op. cit. Medicare and Medicaid Programs, Condition of Participation: Immunization Standard for 16 Schwartz, J. S., et al., “Internists’ Practices in Long Term Care Facilities. Federal Register, Health Promotion and Disease Prevention: 70(194), Friday, October 7, 2005/Rules and A Survey,” Annals of Internal Medicine, 114: Regulations. 46–53, 1991. 31 Other federal partners include Office of Public 17 Ibid. Health and Science, Administration for Children 18 and Families, Administration on Aging, Agency Supra, note 15. for Healthcare Research and Quality, Centers 19 Standing-order programs authorize nurses or for Disease Control and Prevention, Health pharmacists to administer vaccinations according Resources and Services Administration, Indian to an institution- or clinician-approved protocol. Health Service, Office of Intergovernmental Bratzler, D. W., et al., “Failure to Vaccinate Affairs, National Institutes of Health, Office of Medicare Inpatients: A Missed Opportunity,” Disability, and Substance Abuse and Mental Archives of Internal Medicine, 162: 2349–2355, Health Services Administration. November 11, 2002. 32 Centers for Medicare and Medicaid Services, 20 Kicera, T., M. Douglas, and F. Guerra, “Best “CMS Officials Kick Off A Healthier U.S. Practice Models that Work: The CDC’s Racial Starts Here Initiative: National Effort Promotes and Ethnic Adult Disparities Immunization Prevention, Healthier Living,” press release, Initiative (READII) Programs,” Ethnicity and Baltimore, MD, April 20, 2007, Disease, 15 Supplement 3, Spring 2005. http://www.hhs.gov/news/press/2007pres/04/ 21 pr20070420a.html. Ibid. 33 22 Ibid. For more information about the bus tour, Although the projects ended in 2004, an see http://www.healthierus.gov/Prevention/ official evaluation is still pending; ibid. bustour.html. 34 23 Conversation with Maribel Chavez-Torres, READII: Racial and Ethnic Disparities in Immunization Program Director. Chicago Immunization Initiative 2002–2005 Final Report, Department of Public Health. November 30, 2007. It is worth noting that the 35 nationwide flu vaccine shortage of 2004 Ibid. substantially complicated efforts to understand 36 the exact impact of READII’s effectiveness. Ibid. 9 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries 37 48 LTC Reported Immunization Data, provided The Robert Wood Johnson Foundation, Vote by Janet Larson of the Illinois Department of and Vaccinate Grant Results Report, November Public Health, Immunization Program. 2007. http://www.rwjf.org/reports/npreports/ 38 vote.htm. Minnesota Legislature, Legislative Report: 49 Eliminating Health Disparities Initiative, Ibid. Investing in Minnesota’s Populations of Color 50 and Americans Indians, January 15, 2007. Supra, note 49. 51 http://www.health.state.mn.us/ommh/ http://www.voteandvax.org is written, publications/legislativerpt2007.pdf. maintained, and copyrighted by Sickness 39 Ibid. Prevention Achieved through Regional Collaboration, which has organized polling place 40 The CHS is a telephone survey conducted by vaccine clinics for more than 10 years and served the Department of Health and Mental Hygiene, as a model for the current “Vote & Vax” Division of Epidemiology, Bureau of program. Epidemiology Services to provide neighborhood 52 and citywide estimates on a broad range of Singleton J. A., A. J. Poel, et al., “Where chronic diseases and behavioral risk factors. New Adults Reported Receiving Influenza Vaccine in the U.S,” American Journal of Infection Control, York City Department of Health and Mental Hygiene, Community Health Survey, 33(10), December 2005. 53 http://www.nyc.gov/html/doh/html/survey/ http://assembly.state.ny.us/leg/?bn=S8673. survey-2006.shtml. 54 Olenak, J. L., “MTM and Immunizations,” 41 The New York City Department of Health and Pharmacy Today, August 2008. Mental Hygiene Web site uses a function called http://www.pharmacist.com. EpiQuery to present data from surveys and 55 epidemiologic datasets DHMH keeps. These data Rothman R., and M. Weinberger, “The Role of come from the 2006 Community Health Survey Pharmacists in Clinical Care: Where Do We Go (CHS) and were accessed through EpiQuery at From Here?” Effective Clinical Practice, 5(2), http://www.nyc.gov/health/epiquery. March/April 2002. http://www.acponline.org/clinical_information/ 42 New York City Department of Health and journals_publications/ecp/marapr02/rothman.pdf. Mental Hygiene, Bureau of Immunization 56 Outline of Strategies and Plans for Influenza Steyer T. E., K. R. Ragucci, et al., “The Role Season 2006–07, August 2006. of Pharmacists in the Delivery of Influenza Vaccinations,” Vaccine, 23(3), December 2004. 43 Texas SB 1330, Legislative Session 79(R). 57 See also the Statement of Intent included in the Prosser L. A., M. A. O’Brien, et al., “Non- official Bill Analysis, enrolled June 28, 2005. traditional Settings for Influenza Vaccination in http://www.capitol.state.tx.us/BillLookup/ Adults: Costs and Cost Effectiveness,” Text.aspx?LegSess=79R&Bill=SB1330 Pharmacoeconomics, 26(2), 2008. 58 44 Ibid. Supra, note 49. 59 45 Correspondence with Vicki Cowling, Chief Supra, note 23. of Staff of the Division of Regulatory Services, 60 Supra, notes 20 and 23. Texas Department of State Health Services, 61 August 25, 2008. Supra, note 23. 62 46 For two prominent examples, see the efforts in Schwartz, K. L, et al, “Racial Similarities in Virginia, part of Project Immunize Virginia, and Response to Standardized Offer of Influenza early work by SPARC in Connecticut, Vaccination,” Journal of General Internal Massachusetts, and New York. Medicine, 21: 346–351, 2006. 63 47 “Flu Shot Program Is Ended After G.O.P. Shenson, D., “Putting Prevention In Its Place: Cries Politics,” Associated Press, The New York The Shift From Clinic To Community,” Health Times, November 3, 2006. Affairs 25(4): 1012–1015, 2006. http://www.nytimes.com/2006/11/03/us/politics/ 03flu.html. 10 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries Insight on the Issues #12, October, 2008 Written by Lynda Flowers, Shelly-Ann Sinclair and Ben Umans INSIGHT on the Issues AARP Public Policy Institute, 601 E Street, NW, Washington, DC 20049 www.aarp.org/ppi 202-434-3890, ppi@aarp.org © 2008, AARP. Reprinting with permission only. 11