Aris M, Montourcy M, Esterberg E, Kurosky SK, Poston S, Hogea C. The adult vaccination landscape in the US after introduction of the Affordable Care Act – results from a large retrospective database analysis. Poster presented at the 2019 Annual Conference on Vaccinology Research; April 3, 2019. Baltimore, MD.


BACKGROUND: Vaccine coverage rates in US adults are suboptimal, despite recommendations from the Advisory Committee on Immunization Practices and implementation of Affordable Care Act (ACA) provisions in 2011 reduced some access barriers to adult immunization.1 Preventive care visits for adults are timed around risk for specific health issues (e.g., colorectal cancer screening at age 50), and may lead to relatively infrequent opportunities for vaccination.2 Data on adult vaccination and preventive care patterns around the times and ages at which vaccinations are recommended are necessary for understanding whether opportunities for vaccination are available, in which health care settings these opportunities are occurring, and which providers are presenting opportunities. This study aimed to describe characteristics of influenza, Tetanus, diphtheria and pertussis (Tdap), pneumococcal, and herpes zoster (HZ) vaccination in adults and identify potential opportunities for vaccination through analysis of administrative health care claims for insured adults in the US after implementation of ACA.

METHODS: Between 2011 and 2016, adults aged 19+ were selected from the Truven MarketScan Commercial Claims (CCAE), Medicare Supplemental, and Medicaid Multi-State databases. CCAE and Medicare claims were analyzed together to provide a continuous record of claims for patients with private insurance. Medicaid claims were analyzed separately. Vaccination events were identified by Current Procedural Terminology codes or National Drug Codes and subsequently summarized by patient and health plan characteristics, setting, provider, and visit type (e.g., preventive care visit). Potential missed opportunities were defined as preventive care visits (e.g., “wellness” exams or visits where preventive screenings, procedures or therapies were administered) at which individuals were eligible for vaccination but did not receive it. Absence of any preventive care visits during the observation period was categorized as a missed encounter for vaccination. Potential missed opportunities for influenza vaccination were evaluated among adults continuously enrolled during the typical influenza immunization period (September through February). Potential missed opportunities for HZ and pneumococcal vaccination were evaluated among adults continuously enrolled around the age when HZ or pneumococcal vaccination were recommended during the study period (a 36-month period starting January 1 in the year the individual aged 60 and 65 years, respectively). All outcomes were analyzed descriptively.

RESULTS AND CONCLUSIONS: The distribution of vaccination events occurring in the health care setting by type of visit differed by vaccine and payer. Most patients in the CCAE/Medicare sample received influenza, Tdap, and HZ at preventive care visits (56.74%, 51.87%, and 66.78%, respectively), while a large proportion of these vaccinations occurred during non-preventive care visits among Medicaid patients. A consistent trend of increase in vaccinations in the pharmacy setting and decrease in the outpatient setting was also observed across vaccines and payers over time. In the CCAE/Medicare sample, family and internal medicine providers were the most common influenza, Tdap, and pneumococcal vaccination providers, collectively administering 49.08%, 57.66%, and 63.21% of vaccinations, respectively. HZ vaccination events occurred mainly in pharmacies: 44.00% in the CCAE/Medicare sample and 85.19% in the Medicaid sample. Large proportions of individuals in the Medicaid sample had missed encounters: 84.57%, 61.68%, and 50.83% of the continuously enrolled influenza, HZ, and pneumococcal vaccine-eligible cohorts, respectively. In the CCAE/Medicare continuously enrolled samples, 53.20% of the HZ vaccination-eligible cohort and 36.40% of the pneumococcal vaccination-eligible cohort had missed opportunities, while 69.58% of the influenza vaccination-eligible cohort had missed encounters in at least one influenza season. Lack of preventive care visits in the Medicaid cohort and inconsistent inclusion of due vaccinations as part of preventive visits for the CCAE/Medicare patients may contribute to suboptimal vaccination rates. Results of this analysis provide further insight into possible gaps in vaccination delivery and where existing preventive visits may be leveraged to improve adult vaccine uptake.

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