Practice Guidelines
CDC Releases Guidelines for Improving Vaccination Rates Among High-Risk Adults
The Task Force on Community Preventive Services of the Centers for Disease Control and Prevention (CDC) has issued an evidence-based review of interventions to improve influenza, pneumococcal polysaccharide, and hepatitis B vaccination coverage among high-risk adults younger than 65 years. The recommendations were based on a systematic review. The full report appears in the April 1, 2005, issue of Morbidity and Mortality Weekly Report and is available online at http://www.cdc.gov/mmwr/PDF/rr/rr5405.pdf.
Influenza, pneumococcal infections, and hepatitis B cause substantial morbidity and mortality in the United States, especially among persons at high risk (e.g., those with certain medical conditions, occupational exposures, or risky behaviors). Reducing the incidence of these diseases is highly dependent on increasing vaccination coverage among high-risk adults. Although vaccines are effective and widely available, vaccination rates remain low.
The task force performed a systematic review to evaluate the efficacy of interventions used alone or in combination to increase vaccination coverage among high-risk adults younger than 65 years. The review addressed three vaccinations recommended for high-risk adults (i.e., influenza, pneumococcal polysaccharide, and hepatitis B). Intervention categories included enhancing access to vaccination services, providing physician- and system-based interventions, and increasing community and patient demand.
Results
intervention
Although the task force found insufficient evidence to support the efficacy of interventions when used alone, they found that multicomponent interventions may improve coverage rates. Multicomponent interventions reinforce one another, because a patient who receives one intervention may be more receptive to others. Also, multicomponent interventions are more intense than single-component interventions and increase the likelihood that a patient will be exposed to at least one intervention. Specific interventions include:
• Expanded access in health care settings
• Reducing patients' out-of-pocket costs
• Standing orders
• Physician or patient reminder systems and education
• Physician assessment and feedback
The task force recommends combining at least one intervention aimed at enhancing access to targeted vaccination services with at least one physician- or system-based intervention and/or at least one intervention to increase patient demand for vaccination. The accompanying table lists the recommended combinations.
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Task Force on Community Preventive Services Recommended Intervention Combinations to Increase Targeted Vaccinations |
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At least one of the following interventions to enhance access to vaccination services Expanded access in health care settings Reducing patients' out-of-pocket costs plus At least one of the following physician- or system-based interventions Standing orders Physician reminder systems Physician assessment and feedback and/or At least one of the following interventions to increase patient demand for vaccination services Patient reminder systems Patient education |
| Adapted from Centers for Disease Control and Prevention. Improving influenza, pneumococcal polysaccharide, and hepatitis B vaccination coverage among adults < 65 years at high risk. A report on recommendations of the Task Force on Community Preventive Services. MMWR Morb Mortal Wkly Rep 2005;54:8. |
Physician reminders are the only interventions that may effectively improve coverage rates when used alone.
implementation
Community Matching. Implementing interventions that best fit the community's needs and resources is important. Program planning and community assessment should take place before implementing an intervention plan. When matching interventions to local needs, planners should assess existing disparities in vaccine coverage among adult patients with universal and targeted indications. The interventions may also be modified to address barriers to vaccination, although more research is needed.
Hepatitis B. Most of the recommendations are widely applicable. However, few data exist regarding community-based interventions to increase hepatitis B vaccination among health care workers. Although initiatives that effectively improve vaccination rates for other diseases may also be effective for hepatitis B, the effective and recommended health care-based interventions may not be applicable or may need considerable modification.
Practice Guideline Briefs
AAP Releases Report on Excessive Sleepiness in Adolescents
The American Academy of Pediatrics (AAP) has released a technical report on the causes and consequences of adolescent sleepiness. The report, which is based on a meta-analysis, appears in the June 2005 issue of Pediatrics.
Inadequate sleep has become a widespread problem for adolescents. Physicians have an important role in identifying adolescent patients at risk for inadequate sleep and in providing counseling and support to help manage sleep-related symptoms.
Common causes of sleepiness in adolescents include normal changes that occur during the transition into adolescence (e.g., varying sleep/wake times, relaxed parental control of bedtimes, changing school start times). Many adolescents also have part-time jobs that cut into their sleep time. Studies have shown that the biological system that regulates circadian rhythms may change during adolescence, creating a later timing of sleep. Because of these changes, adolescents get less sleep than they did as children. Insomnia, narcolepsy, idiopathic hypersomnia, restless legs syndrome, and numerous medications are also common causes of inadequate sleep in adolescents.
Lack of sleep can affect adolescents' cognitive function, concentration and attention, alertness, and ability to perform in school. Studies have shown that many adolescents who have sleep disorders also have symptoms of attention-deficit/hyperactivity disorder. Adolescents with clinical mood disorders, especially severe depression, report higher incidences of sleep disturbance. Sleepiness is also the leading cause of motor vehicle crashes among drivers 16 to 29 years of age.
The AAP concludes that physicians should recognize the significant problem of sleepiness among their adolescent patients. Physicians need to ask questions about sleep patterns, how much sleep their adolescent patients are getting, and if they are having any sleep-related symptoms. A sleep history should focus on the following points:
• Bedtime problems
• Excessive daytime sleepiness
• Awakenings during the night
• Regularity and duration of sleep
• Sleep-disordered breathing (e.g., loud snoring)
At the least, the AAP recommends educating adolescent patients about their sleep needs and the detrimental effects of sleep loss on performance and health.
CDC Issues Statistics on Percentage of U.S. Population Lacking Health Insurance
The Centers for Disease Control and Prevention (CDC) recently issued statistics on the percentage of persons younger than 65 years without health insurance in the United States. These statistics appear in the April 22, 2005, issue of Morbidity and Mortality Weekly Report and are available online at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5415a4.htm.
According to the CDC report, 16.5 percent of persons younger than 65 years lack health insurance. Of these, approximately one fourth have never had health insurance and one fourth have been without health insurance for more than 36 months. Being without health insurance is linked to reduced access to preventive health care and less consistent care for chronic health conditions.
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| Copyright © 2005 by the American
Academy of Family Physicians. |
