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Pneumococcal, Influenza Vaccine Coverage Needs Improvement

Kate Traynor

Relatively few Medicare beneficiaries receive influenza or pneumococcal vaccination while in the hospital, according to a study sponsored by the Centers for Medicare & Medicaid Services (CMS).

The study, which relied on a sample of medical and Medicare claims records for beneficiaries age 65 or older, found that less than 1 percent of approximately 105,000 elderly patients who could have received the pneumococcal vaccine while in the hospital actually did before discharge. These patients had been hospitalized because of acute myocardial infarction, heart failure, pneumonia, or stroke. Eleven percent of the patients received their annual dose of influenza vaccine while hospitalized during the 12-month study period, which included the 1998–99 influenza season.

The study's results were reported in the Nov. 11 Archives of Internal Medicine.

Inclusion of information about vaccine doses administered before or after hospitalization increased the overall coverage rate for pneumococcal vaccination to about 34 percent and the influenza vaccination rate to 44 percent. Both totals were well below the then-applicable Healthy People 2000 goals, which called for 60 percent of Americans age 65 or older to receive an annual flu shot and at some time a single dose of pneumococcal vaccine.

The Healthy People 2010 goals aim for a 90 percent coverage rate for each of the vaccines in elderly Americans.

Jill True Robke, Pharm.D., a clinical pharmacist at Saint Luke's Hospital of Kansas City, Mo., said her institution relies on pharmacists to boost pneumococcal and influenza vaccination rates.

Robke said an audit several years ago of the hospital's critical pathway for the care of patients with community-acquired pneumonia revealed that the document lacked a place to record whether they had previously received the influenza and pneumococcal vaccines. The hospital revised the pathway to require documentation of patients' vaccination status at admission. Also, the hospital launched a program in which the pharmacists reviewed certain adult patients' risk factors for pneumococcal disease and, when appropriate, recommended administration of the pneumococcal vaccine.

Robke said the program, when initially evaluated from October 1999 through March 2000, boosted the pneumococcal vaccination rate among patients with community-acquired pneumonia or hip fracture to 74 percent, compared with 56 percent before the pharmacists' intervention. But, she said, the need for a physician to approve each vaccination made the process unwieldy.

"The rate-limiting step was alerting physicians," Robke said. "That was just very labor intensive—having to keep going back to the chart to figure out whether or not the physician had seen your note." If the physician had not made a check mark in the box indicating approval to administer the vaccine, Robke said she would reposition her note in the hope that it would now catch the prescriber's attention.

The project gained momentum when it caught the attention of the physician who heads the 650-bed hospital's quality assurance department. St. Luke's, Robke said, needed to comply with a federal requirement to assess the immunization status of Medicare inpatients, and the physician believed that the pharmacy-led program could satisfy the requirement.

A report in the Nov. 15 Morbidity and Mortality Weekly Report estimated that 65 percent of elderly Americans received their annual flu shot last year, and that pneumococcal vaccine coverage has reached 60 percent of Americans age 65 or older.

This finding was based on data obtained from the 2001 Behavioral Risk Factor Surveillance System (BRFSS), a national telephone study conducted by the Centers for Disease Control and Prevention (CDC). Approximately 40,000 people 65 years of age or older responded to the 2001 survey.

According to the report, 49 percent of survey respondents who reported receiving one vaccine had also received the other. Eleven percent of those surveyed said they had received only a pneumococcal vaccination, and 15 percent reported a recent flu shot but no pneumococcal vaccine. Twenty-five percent of the survey respondents had not received either vaccine.

BRFSS data indicate that influenza vaccination reached a plateau in 1999 and then fell slightly through 2001, a phenomenon that CDC attributed, in part, to the vaccine supply problems of the past two years.

"We must expand our efforts to improve vaccination rates if we hope to reach our national health objectives of 90 percent coverage for these two vaccines in elderly Americans by the year 2010," said Jim Singleton, an adult immunization expert from CDC's National Immunization Program, during a Nov. 14 media briefing.

"Health care providers should offer pneumococcal vaccine throughout the year at every opportunity and should continue to offer influenza vaccine during December and throughout the flu season, even after flu activity has been documented in the community," he said.

This support led to the development, a year ago, of a collaborative practice agreement between the pharmacists and the physicians. Through the agreement, a pharmacist assesses a patient's influenza and pneumococcal vaccination status at admission and offers to have a nurse administer the vaccine unless it is contraindicated. Robke said the agreement automatically applies to physicians who practice at the hospital. Few physicians, she said, requested exclusion from the agreement.

Since the collaborative practice agreement took effect, Robke said, the hospital's pneumococcal vaccination rate for adult patients with community-acquired pneumonia has approached 90 percent. Influenza vaccination rates are also on the rise.

"We vaccinated about 400 inpatients during flu season last year, and that was with a two-week interruption in our [influenza] vaccine supply ... at the end of October," she said.

This October alone, Robke said, the hospital has administered about 250 flu shots and 70 pneumococcal vaccine doses to elderly inpatients and younger patients who are at risk for complications from influenza or pneumonia.

"We're getting to the Healthy People 2010" goal, she said, "and that has a lot to do with the collaborative practice agreement."

The recent CMS-sponsored study similarly noted that "standing orders programs that authorize nurses or pharmacists to administer vaccinations according to an institution- or physician-approved protocol" seem to produce the highest inpatient vaccination rates. In support of this finding, CMS on Oct. 2 issued a final rule in the Federal Register (PDF) that lifted the requirement for physicians to order pneumococcal and influenza vaccination of Medicare and Medicaid beneficiaries in hospitals or long-term care facilities or under the care of home health agencies. The rule paves the way for health care providers other than physicians to administer the vaccines through the use of a standing-order protocol in states that allow this mechanism.

According to the final rule, "none of the successful [vaccination] programs described thus far in the literature has depended on active physician participation. Instead, nurses or pharmacists have been responsible for their implementation."

Robke said she is convinced that the participation of pharmacists greatly added to the success of the vaccination program at St. Luke's.

"Pharmacists are ideally suited to do this," she said, adding that the public has many misconceptions about vaccines. "We're in the position to educate people so that they know the true risks and benefits" of vaccination.

Robke noted that many patients say the inpatient vaccination program eases their worry about finding a way to obtain a pneumococcal or flu shot. The program can also provide personal satisfaction for pharmacists.

"One of the things I love about doing this is that it gets you into the patient's room," Robke said. "You get some face-to-face exposure." Patients, she said, "realize that they have a pharmacist looking out for them."