AARP Public Policy Institute INSIGHT on the Issues Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries Despite lack of Medicare cost sharing for the flu and pneumonia vaccines, substantial racial and ethnic disparities in immunization rates persist. This Insight on the Issues discusses current recommendations for adult immunization, current Medicare coverage policies, and federal and state initiatives that show promise in reducing disparities in immunization rates. Introduction Adult Immunization Recommendations and Influenza (commonly called flu) and Medicare Coverage pneumonia are both vaccine-preventable diseases. Yet together they represented The Medicare population is especially the eighth leading cause of death in the susceptible to complications associated United States and the sixth leading cause with flu and pneumonia because both of death among persons age 65 and older diseases often exacerbate underlying in 2005.1 Influenza is responsible for chronic conditions, such as heart or lung approximately 36,000 deaths and more disease, asthma, and diabetes.6 than 200,000 hospitalizations each year in the United States. More than 90 The Advisory Committee on percent of these deaths occur among Immunization Practices (ACIP) is those ages 65 and older.2 Pneumococcal an expert panel selected by the Secretary pneumonia affects about 33,000 persons of the U.S. Department of Health and a year, resulting in 5,000 deaths. Similar Human Services to advise the nation on to flu, most of the deaths caused by how to reduce vaccine-preventable pneumonia occur among those ages 65 diseases. The ACIP, which develops and older.3 standards for routine vaccine administration, including dosage, Flu and pneumonia immunization rates periodicity schedules, and applicable among all older adults are significantly contraindications for pediatric and adult below the Healthy People 2010 goals of populations, recommends the following: 90 percent for each vaccine.4 However, immunization rates among African An annual influenza vaccine for Americans and Hispanics are adults ages 50 and older, and for all substantially below those of their white persons who live in long-term care counterparts.5 facilities, and A one-time vaccination for pneumococcal pneumonia for all adults age 65 and older.7 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries The Medicare Program covers In 2008, 70 percent of white adults age pneumococcal and influenza vaccines for 65 and older reported receiving the persons age 65 and older in accordance influenza vaccine. During the same with ACIP recommendations. Medicare period, 50.2 percent of older African pays for both the cost of the vaccines and Americans and 54.9 percent of older their administration by participating Hispanics reported having received the providers. Once five years have elapsed flu vaccine (Figure 1). Influenza since the initial pneumococcal vaccine, a immunization disparities persist, even booster vaccine is covered for persons in after controlling for other factors such as high-risk categories.8 socioeconomic status and the presence of risk factors for influenza.10 Flu There is no coinsurance or copayment immunization rates actually dropped associated with either vaccine, and among older African Americans between beneficiaries are not required to meet the 2007 and 2008, from 55.3 to 50.2 annual Medicare deductible in order to percent. receive them.9 The gap is even wider for pneumonia Disparities in Immunization Rates immunization rates, with only 44.6 among Medicare Beneficiaries percent of African Americans and 36.4 percent of Hispanics reporting having Despite Medicare’s coverage of influenza been vaccinated in 2008, compared with and pneumonia vaccines at no out-of- 64.5 percent of their white counterparts pocket cost to beneficiaries, the number of (Figure 2). people who are immunized is less than optimal, with even lower rates noted The social cost of immunization among African Americans and Hispanics. disparities is preventable hospitalizations and deaths. A 2007 study estimated that Figure 1 Influenza Immunization Rates for Population Age 65+ by Race/Ethnicity 1999–2008 80 60 Percent 40 20 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Hispanic or Latino White only Black or African American only Source: National Health Interview Survey, 1999 to 2008. 2 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries Figure 2 Pneumococcal Immunization Rates for Population Age 65+ by Race/Ethnicity 1999–2008 80 60 Percent 40 20 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Hispanic or Latino White only Black or African American only Source: National Health Interview Survey, 1999 to 2008. if flu immunization rates were equal for Few consumer-initiated visits to all races, 1,880 minority deaths could be providers to receive the vaccines;16 prevented every year, saving more than Provider underestimation of the 33,000 minority life years.11 Moreover, safety and efficacy of the vaccines;17 if all racial groups achieved the national Provider lack of familiarity with Healthy People 2010 goal of 90 percent age-based immunization flu vaccination, 15,590 elderly deaths recommendations;18 could be prevented annually.12 Provider failure to recommend age-appropriate immunizations to Factors Associated with Racial and Ethnic Immunization older adults;19 and Disparities among Medicare Provider failure to institute standing- Beneficiaries order programs despite ACIP recommendations to use them. 20 Researchers have associated the following factors with low flu and Federal Initiatives to Address pneumococcal pneumonia immunization Immunization Disparities rates among African Americans and Hispanics: In 2002, the Centers for Disease Control and state health departments, initiated Consumer lack of awareness about the Racial and Ethnic Adult Disparities the need for the vaccinations;13 in Immunization Initiative (or READII, Consumer fear that the vaccines will pronounced “ready”) to address racial cause severe illness;14 and ethnic disparities in immunization rates among African American and Distrust of flu immunization due to Hispanic Medicare beneficiaries.21 lingering memories of the Tuskegee syphilis experiments;15 The READII project was launched in five sites and targeted different ethnic 3 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries groups. Projects in Milwaukee, coverage between year 1 and year 3 of Wisconsin, 19 counties in the the project.24 Mississippi delta region, and those in Rochester, New York targeted an older Interventions such as clinic-based African American Population. The San tracking, outreach, and patient recall Antonio, Texas project targeted elderly were identified as effective strategies for Hispanics; and the Chicago, Illinois the little improvement in flu and project targeted both racial groups. pneumonia vaccination among African Americans and Hispanics experienced at Although the project designs and some of the READII sites.25 targeted population varied among the project sites, all projects shared three The most successful efforts targeted underlying strategies: providers.26 For example, outreach workers in Rochester clinics used a Develop local buy-in to the project patient database to monitor seniors, design; provided direct reminders to patients by Engage stakeholders (persons age 65 telephone and mail, and alerted providers and older); and to unvaccinated patients with chart Use evidence-based interventions reminders and prompts.27 with providers and in the These strategies, combined with broader community.22 outreach efforts, resulted in 80 percent The project lasted from August 2002 of seniors receiving the pneumonia through December 2004 with wrap up and vaccine over the two-year period and evaluation activities through June 2005. substantial increases in flu vaccination across racial groups.28 It should be noted Each READII site developed community that Rochester’s successful interventions plans, undertook communications research depended on outside funding, making to determine which messages resonated its outcomes difficult to replicate in best with older African American and areas with fewer available resources.29 Hispanic community members, and held local community events. In Mississippi, making offers of vaccination a standard part of health Strategies aimed at providers included clinic visits raised immunization rates education about standing orders (e.g., a for all racial groups.30 notation in a patient’s medical record that prompts the provider to Collaboration with local groups—private automatically provide a flu or foundations, local clinics and pneumonia vaccine to a patient), patient community health centers, media outlets, reminders and recalls, and provider faith-based organizations, professional reminders.23 organizations, and AARP—varied among READII sites depending on the The outcomes of READII were mixed, local environment and helped lay a but provide important evidence and foundation for future community health strategies for future efforts. Overall, flu interventions.31 vaccination rates decreased between year 1 and year 3 because of the fall 2004 flu One of the biggest challenges vaccine shortage. Additionally, there encountered by READII project sites was no statistically significant increase was getting health care providers to shift in overall pneumonia vaccination their focus from treating acute and chronic illness in an older population to 4 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries a focus on providing comprehensive community collaborations that have preventive services.32 lasted beyond the conclusion of the CDC study. During flu season, the CDPH runs Another federal effort to increase eight weekend faith-based vaccine immunization rates among older persons clinics and promotes vaccine use in was focused on residents of long-term target communities.37 About 16,000 care facilities. The Centers for Medicare vaccines were administered in the 2007– and Medicaid Services (CMS) issued 2008 flu season, with the greatest final rules on October 7, 2005, requiring success reported in churches in the Medicare and Medicaid long-term care Hispanic community, though use in facilities to offer flu and pneumococcal African American faith communities is vaccines to their residents. Long-term increasing.38 Because some of the care facilities are required to document elderly are unable to come to CDPH refusals and indicate that the resident or weekend clinics, the city supplied the his or her legal representative received vaccine to providers in the communities appropriate education and consultation. where the READII project operated.39 Although African Americans and Statewide, long-term care facilities are Hispanics are not targeted in the rule, required to respond to a survey of those living in nursing homes can benefit immunization practices. The most recent from this policy.33 survey found that 70.1 percent of residents received a flu vaccine in the Together with its partners,34 CMS 2007–2008 season and 48.8 percent had conducted a cross-country bus tour, titled received a pneumonia vaccine in the “A Healthier U.S. Starts Here,” during previous five years.40 spring and summer of 2007 to promote awareness of Medicare’s prevention Minnesota benefits, including flu and pneumococcal immunizations. Although the tour did not In 2001, the Minnesota legislature created specifically address immunization the 10-year, statewide Eliminating disparities, African American and Health Disparities Initiative (EHDI) to Hispanic beneficiaries were among the address health disparities in the state. targeted groups.35 The tour reached the 48 The goal of the initiative is to fund a continental states with information about variety of projects that promote culturally prevention and wellness.36 appropriate, community-based public health programs.41 State Strategies to Address Recently, Minnesota enacted legislation Immunization Disparities to further the goals of the EHDI by States use a variety of strategies to creating a community grant program increase immunization rates among older aimed at, among other things, increasing adults, including Medicare beneficiaries. immunization rates in nonwhite racial Some of these activities are described and ethnic populations. Organizations below. eligible for grants include faith-based organizations, social service Illinois organizations, community nonprofit organizations, community health boards, The Chicago Department of Public tribal governments, and community Health (CDPH) partners with clinics. To qualify for funding, the community groups to provide increased organizations must target racially and access to immunizations in high-risk ethnically appropriate populations and communities. As one of the READII project sites, Chicago developed 5 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries must have a specific strategy in place to pneumonia vaccines to patients admitted reach the target group.42 for more than 24 hours.47 Hospital licensing rules in Texas now include this New York requirement.48 The New York City Department of Health and Mental Hygiene’s Bureau Linking Vaccination with Voting of Immunization (the Bureau) uses data from the annual New York City Several states and nonprofit organizations Community Health Survey (CHS) to have worked with local election obtain neighborhood and citywide authorities to set up vaccine clinics at or estimates of immunization rates among near polling places.49 These initiatives are targeted populations.43 According to known as the Vote and Vax program, a 2008 CHS data, 49 percent of African collaboration between The Robert Wood Americans and 55.7 percent of Hispanics Johnson Foundation and a nonprofit age 65 and older reported receiving the agency called Sickness Prevention influenza vaccination within the past Achieved through Regional Collaboration year, compared with 58.8 percent of or SPARC. Vote and Vax works with all their white counterparts.44 In addition, local public health providers seeking to 48.3 percent of African Americans and offer convenient flu vaccination at polling 41 percent of Hispanics age 65 and older places across the country. reported having ever received a Pairing vaccination with voting is pneumococcus vaccine, compared with an innovative strategy and has been 53.9 percent of their white counterparts. shown to be effective. The elderly are Bureau activities to address consistent voters, making polling places immunization disparities include the good sites for reaching high-priority following: individuals. Furthermore, elections occur during the recommended flu Working with medical providers immunization season. to address provider behavior and strengthen their actions to immunize The influenza vaccine can be their patients; administered quickly and, since no follow-up is needed, Election Day Developing partnerships with a variety of community-based clinics can supplement the efforts of organizations to educate and primary care providers. Most important, vaccination efforts carried out at the motivate consumers to seek local level can better target outreach immunizations; and strategies designed to reach individuals Working with media outlets to within those communities. design and promote culturally appropriate messages.45 On Election Day 2008, Vote and Vax delivered nearly 21,500 influenza vaccines Texas at 330 election sites in 42 states and the In 2005, the Texas Legislature passed District of Columbia.50 Of those legislation (Senate Bill 1330) seeking vaccinated, almost half (48 percent) were to increase availability of flu and “new recipients,” meaning they either had pneumonia vaccines to the elderly.46 The not received a flu shot in the previous year law requires hospitals, dialysis centers, or would not have received a vaccination and doctors’ offices to provide without the program.51 Two-thirds of the information about vaccination to elderly adults who were immunized through patients and to directly offer flu and the Vote & Vax 2008 Program were in 6 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries CDC-defined “priority groups,” which is economic savings: Research from include persons over 50.52 2008 demonstrated that vaccination in a pharmacy is less costly than in a Unlike interventions targeted to elderly scheduled doctor’s office visit or other and minority populations, Election Day “traditional settings.”58 clinics cannot limit their outreach to subsets of the general population (e.g., the Making Providers Accountable elderly or minorities) while maintaining their political neutrality. Charges that Health care providers are an important vaccination efforts are attempts to “get out part of the vaccination challenge. the vote” and bring specific demographic Providers are trusted and respected by groups to the polls resulted in the closure many patients and are uniquely able to of one clinic in 2006.53 identify and educate at-risk patients about the benefits of prevention and Pharmacists as Providers allay concerns about risks of vaccinations. For many patients, the The CDC has urged increasing access to advice of a health care provider may vaccination services “in nontraditional carry more weight than public health settings as another strategy in pursuit literature and outreach campaigns. of national vaccination coverage objectives.”54 Every state has enacted laws In some types of health care organizations, permitting pharmacists to administer providers may realize the cost savings of certain vaccines. Many states also allow preventions. Influenza and pneumococcal other licensed health care professionals to immunization can prevent costly treatment provide immunizations. The most recent of these diseases, and providers may be law was enacted in October 2009 in able to realize cost savings by vaccinating Maine. Flu immunization clinics held each more of their patients. fall in retail settings have become common, but some community-based In recent years, CMS (like other large pharmacists are trained and prepared to purchasers) has promoted accountability offer other vaccines year-round. Since among its contracting providers by 1996, more than 40,000 pharmacists and publishing reports that compare pharmacy students have been trained performance on various evidence-based in vaccine information and vaccine measures, including immunization rates administration through the American for flu and pneumonia for older adults Pharmacists Association Immunization enrolled in Medicare. Giving consumers Delivery Program.55 access to comparative information helps them choose high-performing clinicians, For nearly a decade, the American facilities, and health plans. In addition, College of Physicians–American Society there is evidence that health plans that of Internal Medicine has supported publicly report quality measures, such as pharmacists as immunizers.56 Further, immunization rates, tend to do better on research has demonstrated a public such measures than plans that do not. health benefit: One study found that Thus, even if consumers do not use persons age 65 and older who lived in quality measures for decision-making, states where pharmacists were allowed providers do focus on areas for which to provide vaccines had significantly they are held publicly accountable. higher flu vaccine rates than those who lived in jurisdictions where pharmacists’ Medicare currently requires health plans scope of practice did not include participating in the Medicare Advantage vaccination.57 Another important benefit program to collect and report data on flu 7 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries and pneumococcal vaccination rates. from person to person in the same These results are published on manner as the seasonal flu. Symptoms of www.Medicare.gov. In addition, CMS’s the H1N1 flu—fever, cough, body Physician Quality Reporting Initiative aches—are also very similar to those of (PQRI) includes flu and pneumonia the regular seasonal flu. The primary measures and offers financial incentives difference between the two types of flu to physicians who report them. is susceptible age groups. Some plans go beyond public reporting Unlike seasonal flu, where older adults to base provider payments on their are more likely to contract the virus, performance. Providers in these plans groups at higher risk of contracting receive a financial bonus if they perform H1N1 include pregnant women, those well on quality measures; for example, if ages 6 months to 24 years, and they have high immunization rates they individuals with chronic conditions. The are rewarded financially. CDC recommends that these groups receive the vaccine as soon as it Challenges becomes available. Although the CDC is encouraging seniors to get both seasonal Despite the success of small-scale, local and H1N1 vaccines, older adults are not initiatives, sustainability and broader reach in the priority group to receive H1N1 remains a concern. Programs that operate before those at higher risk. Medicare locally and depend heavily on local covers the H1N1 vaccine and exempts it resources, funding, and staffing from year from the Part B deductible and to year may not last. Election Day clinics coinsurance.63 Thus, financial have cited difficulty obtaining the vaccine constraints should not be a barrier to as a continuing challenge, as well as receipt of the vaccine. Although no data securing long-term funding commitments regarding racial and ethnic disparities from public health agencies that do not among seniors receiving the H1N1 prioritize adult immunization.59,60 Flu vaccine currently exists, it is highly vaccines must be administered annually, likely that the receipt of H1N1 and and the ad hoc nature of many public seasonal flu vaccines will be similar. health vaccination efforts undermines the effectiveness of prevention. Conclusion The key challenge remains reaching the Although the Medicare program pays target population: READII showed that for influenza and pneumococcal offering vaccines directly and making vaccinations for all beneficiaries, racial patient and provider reminders routine and ethnic disparities persist among dramatically improved vaccine usage in African Americans, and Hispanics. A minority populations.61 Nevertheless, 2006 study showed that, when vaccines these strategies require funding and are offered to all persons 65 years or personnel from a public health system older in a clinical setting in the same and primary care community that often manner, the single most important factor face competing priorities for financial determining flu vaccination is past and human resources.62 receipt of flu vaccine.64 Swine Flu In the 2006 study, age, gender, education, and race were all inconsequential if a The 2009 H1N1 influenza, often referred person received a vaccine the prior year. to as “swine flu,” is caused by a new This is encouraging in the face of strain of flu virus. H1N1 virus spreads disparities because it implies that 8 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries vaccination efforts will become easier to Pneumococcal Immunization (Adults, 65+) sustain as they progress and people’s http://www.prevent.org/content/view/57/100/ habits change. It also emphasizes a role for 4 Healthy People 2010 is a set of health providers in promoting vaccine use. objectives for the nation to achieve over the first Evidence from local-level studies supports decade of the new century. Healthy People 2010 the prediction of Douglas Shenson, the was developed through a broad consultation Director of SPARC: “If preventive process, built on the best scientific knowledge, services are placed within easy reach and designed to measure programs over time. across the community, and if health U.S. Department of Health and Human Services, Office of Disease Prevention and Health professionals provide straightforward Promotion, Healthy People, accessed at messages about their effectiveness, more http://www.healthypeople.gov/About/ Americans will take advantage of their whatis.htm. availability,” to the betterment of the 5 U.S. Department of Health and Human population as a whole.65 Services, Office of Disease Prevention and Health Promotion, Healthy People, accessed at There are promising strategies to promote http://www.healthypeople.gov/About/ influenza and pneumococcal whatis.htm. immunization among the general 6 Nichol, K.L., Wuorenma J., and von Sternberg, population, as well as efforts targeted at T., “Benefits of Influenza Vaccination for Low-, African Americans and Hispanics. The Intermediate-, and High-Risk Senior Citizens,” challenge is twofold: educating patients Archives of Internal Medicine, 158: 1769–1776, about the benefits of vaccination so they September 14, 1998; Centers for Disease Control and Prevention, “Influenza and Pneumococcal can engage in responsible disease Vaccination Coverage among Persons Age ≥65 prevention, and educating providers and Years and Persons Aged 18–64 Years with health systems about the importance of Diabetes or Asthma—United States, 2003,” prioritizing adult vaccination. The success Morbidity and Mortality Weekly Review, 53(43), of targeted short-term efforts depends on a November 5, 2004. 7 broader strategy that emphasizes a Centers for Disease Control and Prevention, sustained commitment to increase National Immunization Program, Advisory immunization rates among all populations. Committee on Immunization Practices, http://www.cdc.gov/vaccines/recs/default.htm. 8 Persons who receive a pneumococcal vaccine before age 65 should receive another dose after they turn age 65 and five years have elapsed since their first dose. Persons with the following 1 National Center for Health Statistics, Health, conditions should receive a booster vaccine: United States, 2008, with Special Feature on the functional or anatomic asplenia (e.g., sickle cell Health of Young Americans (Hyattsville, MD: disease, splenectomy), human immunodeficiency U.S. Department of Health and Human Services, virus (HIV) infection, leukemia, lymphoma, 2008). Hodgkin’s disease, multiple myeloma, 2 Partnership for Prevention, Strengthening Adult generalized malignancy, chronic renal failure, Immunization: A Call to Action (Washington, nephritic syndrome, or other conditions DC: Medicare and Medicaid Programs); associated with immunosuppression, such as “Condition of Participation: Immunization organ or bone marrow transplantation, and Standard for Long Term Care Facilities,” those receiving immunosuppressive Federal Register, 70(194), Friday, October 7, chemotherapy. Centers for Disease Control and 2005/Rules and Regulations. Influenza Prevention, “Recommended Adult Immunization Immunization Table – Influenza Vaccine Schedule—United States, October 2006– (Adults) http://www.prevent.org/ September 2007,” Mortality and Morbidity Weekly content/view/55/98/ Report, 55(40), Q1–Q4, October 13, 2006, http://www.cdc.gov/mmwr/preview/mmwrhtml/ 3 Partnership for Prevention, op. cit. mm5540a10.htm; Centers for Medicare and Pneumococcal Immunization Table – Medicaid Services, Adult Immunization. 2009– 9 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries 15 2010 Immunizers’ Question and Answer Guide “African Americans leery of vaccine,” to Medicare Coverage of Seasonal Influenza and University of Buffalo, UB Reporter, October 21, Pneumococcal Vaccinations: Steps to Promoting 2009. Wellness Adult Immunizations. 16 http://www.cms.hhs.gov/adultImmunizations/ . Winston, C. A., Wortley, P.M., and Lees, K.A., “Factors Associated with Vaccination of 9 Centers for Medicare and Medicaid Services, Medicare Beneficiaries in Five U.S. Adult Immunization. Communities: Results from the Racial and 10 Ethnic Adult Disparities in Immunization Herbert, P.L., et al., “The Causes of Racial and Initiative Survey, 2003,” Journal of the Ethnic Differences in Influenza Vaccination American Geriatric Society, 54: 303–310, 2006. Rates among Elderly Medicare Beneficiaries,” 17 Health Services Research, 40(2), April 2006. Schwartz, J. S., et al., “Internists’ Practices in 11 Health Promotion and Disease Prevention: Fiscella, K., et al., “Impact of influenza A Survey,” Annals of Internal Medicine, 114: vaccination disparities on elderly mortality in the 46–53, 1991. United States,” Preventive Medicine, 45: 83–87, 18 2007. A “minority life year” refers to a year of Schwartz, J. S., et al., “Internists’ Practices in life lived by minority persons across the Health Promotion and Disease Prevention: population. Thus, when Fiscella et al. estimate A Survey,” that eliminating annual flu vaccine disparities 19 over age 65 would save 33,090 minority life Winston, C. A., Wortley, P.M., and Lees, years, they mean that 33,090 years of life would K.A., 2006. 20 be gained by minority populations as a whole. Standing-order programs authorize nurses or 12 Healthy People 2010 is a Department of pharmacists to administer vaccinations according Health and Human Services set of goals seeking to an institution- or clinician-approved protocol. 21 to raise longevity and health quality while Kicera, T. J, Douglas, M., and Guerra, F., eliminating disparities in the U.S. population. “Best Practice Models that Work: The CDC’s The program goals include 28 focus areas, Racial and Ethnic Adult Disparities including raising influenza and pneumococcus Immunization Initiative (READII) Programs,” immunization rates for the elderly to Ethnicity and Disease, 15 Supplement 3, Spring 90 percent. For more information, see 2005. http://www.healthypeople.gov. 22 Kicera, T., M. Douglas, and F. Guerra, 2005. 13 The Council of State Governments, “Best Practice Models that Work.” “Protecting Our Communities: Programs to 23 Reduce Adult Immunization Disparities,” Kicera, T., M. Douglas, and F. Guerra, 2005. Healthy States Brief, 1(8), August 2006; “Best Practice Models that Work.” Although the Winston, C. A., Wortley, P.M., and Lees, K.A., projects ended in 2004, an official evaluation is “Factors Associated with Vaccination of still pending. Medicare Beneficiaries in Five U.S. 24 READII: Racial and Ethnic Adult Disparities Communities: Results from the Racial and in Immunization Initiative 2002–2005 Final Ethnic Adult Disparities in Immunization Report, November 30, 2007. It is worth noting Initiative Survey, 2003,” Journal of the that the nationwide flu vaccine shortage of 2004 American Geriatric Society, 54: 303–310, 2006. substantially complicated efforts to understand 14 Centers for Disease Control and Prevention, the exact impact of READII’s effectiveness. “Racial/Ethnic Disparities in Influenza and 25 READII: Racial and Ethnic Adult Disparities Pneumococcal Vaccination Levels Among in Immunization Initiative 2002–2005 Final Persons Aged ≥ 65 Years—United States, 1989– Report, November 30, 2007. It is worth noting 2001,” Morbidity and Mortality Weekly Review, that the nationwide flu vaccine shortage of 2004 52(40); Winston, C. A., Wortley, P.M., and Lees, substantially complicated efforts to understand K.A., “Factors Associated with Vaccination of the exact impact of READII’s effectiveness. Medicare Beneficiaries in Five U.S. 26 Communities: Results from the Racial and READII. Ethnic Adult Disparities in Immunization 27 READII. Initiative Survey, 2003,” Journal of the 28 American Geriatric Society, 54: 303–310, 2006. READII. The pneumonia vaccination rates are remarkably consistent, with 79 percent of 10 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries 39 African American and white seniors and 78 Telephone conversation with Maribel Chavez- percent of Hispanic seniors receiving the Torres. vaccine. The results for influenza are less clear 40 because of the 2004 vaccine shortage. In the LTC Reported Immunization Data, provided 2003–2004 flu season, 64 percent of patients in the by Janet Larson of the Illinois Department of Public Health, Immunization Program. intervention group (60 percent of African 41 Americans, 68 percent of whites) were Minnesota Department of Health, Office of vaccinated compared with 22 percent in the Minority and Multicultural Health, Minnesota’s control group (25 percent of African Americans, Eliminating Health Disparities Initiative: 10 percent of whites). In 2004–2005, the year of Overview and History, April 2008. the shortage, late-season vaccination resulted in http://www.health.state.mn.us/ommh/grants/ehdi 62 percent of African Americans and 71 percent /ehdioverview080812.pdf. of white seniors being vaccinated. 42 Minnesota Statutes 2009 145.928, Eliminating 29 READII. Health Disparities. 30 https://www.revisor.leg.state.mn.us/data/revisor/ READII. statute/2009/145/2009-145.928.pdf. 31 READII. 43 The CHS is a telephone survey conducted by 32 READII. the Department of Health and Mental Hygiene, 33 Division of Epidemiology, Bureau of Medicare and Medicaid Programs, “Condition Epidemiology Services to provide neighborhood of Participation: Immunization Standard for and citywide estimates on a broad range of Long Term Care Facilities,” Federal Register, chronic diseases and behavioral risk factors. New 70(194), Friday, October 7, 2005/Rules and York City Department of Health and Mental Regulations. Hygiene, Community Health Survey, 34 Other federal partners include Office of Public http://www.nyc.gov/html/doh/html/survey/ Health and Science, Administration for Children survey-2007.shtml. and Families, Administration on Aging, Agency 44 The New York City Department of Health and for Healthcare Research and Quality, Centers Mental Hygiene (DHMH) Web site uses a for Disease Control and Prevention, Health function called EpiQuery to present data from Resources and Services Administration, Indian surveys and epidemiologic datasets DHMH Health Service, Office of Intergovernmental keeps. These data come from the 2008 Affairs, National Institutes of Health, Office of Community Health Survey (CHS) and were Disability, and Substance Abuse and Mental accessed through EpiQuery at Health Services Administration. http://www.nyc.gov/health/epiquery. 35 Centers for Medicare and Medicaid Services, 45 New York City Department of Health and “CMS Officials Kick off a Healthier U.S. Mental Hygiene, Bureau of Immunization Starts Here Initiative: National Effort Promotes Outline of Strategies and Plans for Influenza Prevention, Healthier Living,” press release, Season 2006–07, August 2006. Baltimore, MD, April 20, 2007, 46 http://www.hhs.gov/news/press/2007pres/04/ Texas SB 1330, Legislative Session 79(R). pr20070420a.html. See also the Statement of Intent included in the 36 official Bill Analysis, enrolled June 28, 2005. Centers for Medicare and Medicaid Services, http://www.capitol.state.tx.us/BillLookup/ “CMS Officials Kick off a Healthier U.S. Text.aspx?LegSess=79R&Bill=SB1330. Starts Here Initiative. For more information 47 about the bus tour, see Texas SB 1330, Legislative Session 79(R). http://www.healthierus.gov/Prevention/ 48 Correspondence with Vicki Cowling, Chief bustour.html. of Staff of the Division of Regulatory Services, 37 Telephone conversation with Maribel Chavez- Texas Department of State Health Services, Torres, Immunization Program Director, August 25, 2008. Chicago Department of Public Health. 49 For two prominent examples, see the efforts in 38 Telephone conversation with Maribel Chavez- Connecticut’s Yale School of Public Health Vote Torres. and Vax program, and work by SPARC nationwide. 11 Racial and Ethnic Disparities in Influenza and Pneumococcal Immunization Rates among Medicare Beneficiaries 50 61 Robert Wood Johnson Foundation, “National Kicera et al., “Best Practice Models that Influenza Vaccine Summit Recognizes SPARC Work”; READII. for the Success of the Vote & Vax 2008 62 Program,” March 30, 2009. READII. 63 http://www.rwjf.org/vulnerablepopulations/prod Centers for Medicare and Medicaid Services, uct.jsp?id=40588. “Medicare’s Coverage of the H1N1 Flu Vaccine,” INSIGHT on the Issues 51 Robert Wood Johnson Foundation, “National October 2009. http://www.medicare.gov/ Influenza Vaccine Summit Recognizes SPARC.” Publications/Pubs/pdf/11439.pdf. 64 52 Schwartz, K. L, et al., “Racial Similarities in Robert Wood Johnson Foundation, “National Influenza Vaccine Summit Recognizes SPARC.” Response to Standardized Offer of Influenza Vaccination,” Journal of General Internal 53 “Flu Shot Program Is Ended After G.O.P. Medicine, 21: 346–351, 2006. Cries Politics,” Associated Press, The New York 65 Times, November 3, 2006. Shenson, D., “Putting Prevention in Its Place: The Shift From Clinic to Community,” Health 54 Singleton J. A., et al., “Where Adults Reported Affairs, 25(4): 1012–1015, 2006. Receiving Influenza Vaccine in the U.S.,” American Journal of Infection Control, 33(10), December 2005. 55 Olenak, J. L., “MTM and Immunizations,” Insight on the Issues 12R, January, 2010 Pharmacy Today, August 2008. http://www.pharmacist.com. Written by Lynda Flowers, Shelly-Ann 56 Rothman R., and Weinberger, M., “The Role Sinclair, Carlos Figueiredo, Ben Umans, and of Pharmacists in Clinical Care: Where Do We Samantha O’Leary Go From Here?” Effective Clinical Practice, AARP Public Policy Institute, 5(2), March/April 2002. 601 E Street, NW, Washington, DC 20049 http://www.acponline.org/clinical_information/ www.aarp.org/ppi journals_publications/ecp/marapr02/rothman.pdf. 202-434-3890, ppi@aarp.org 57 Steyer T. E., et al., “The Role of Pharmacists © 2010, AARP. in the Delivery of Influenza Vaccinations,” Reprinting with permission only. Vaccine, 23(3), December 2004. 58 Prosser. L.A., et al., “Non-traditional Settings for Influenza Vaccination in Adults: Costs and Cost Effectiveness,” Pharmacoeconomics, 26(2), 2008. 59 Robert Wood Johnson Foundation, Vote and Vaccinate Grant Results Report, November 2007. http://www.rwjf.org/reports/npreports/vote.htm. 60 READII. 12