Vaccination Programs: Standing Orders

This review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice and policy related to increasing appropriate vaccination.

The systematic review included 35 studies.

• Overall, vaccination rates increased by a median of 24 percentage points (27 studies).
  • Standing orders used alone increased vaccination rates by a median of 16 percentage points (9 studies).
  • Standing orders used in combination with additional interventions increased vaccination rates by a median of 27 percentage points (19 studies).
• Standing orders increased vaccination rates among children by a median of 28 percentage points (4 studies).
• All of the studies that did not provide a common measure of change for vaccination rates reported favorable results (7 studies).

Three U.S. studies that evaluated the economics of standing orders for pneumococcal, influenza, and Tdap vaccines were included in the economic review (search period 1980 2012). All monetary values are reported in 2013 U.S. dollars.

• The median intervention cost was $5.55 per person per year (3 studies).
• The median cost was $29 per additional vaccinated person (3 studies).
• Intervention groups had a median size of 11,813 clients (3 studies).

• Various clinical settings (e.g., clinics, hospitals, long-term care facilities)
• Different vaccination providers (e.g., nurses, pharmacists)
• Children, adolescents, and adults
• Inpatient and outpatient settings

• How effective are these interventions for adolescent populations?
• How effective are these policies in communities with disparities in vaccination rates?
• What are strategies to address implementation barriers for standing orders in systems of care?

• Included studies were conducted in a wide range of clinical settings, including healthcare clinics, hospitals, and long-term care facilities.
• Evaluated interventions were used with different vaccination providers including nurses and pharmacists.

Effectiveness Review

Analytic Framework

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Economic Review

No content is available for this section.

Effectiveness Review

Summary Evidence Table – Effectiveness Review

Economic Review

No content is available for this section.

Effectiveness Review

Bardenheier BH, Shefer A, McKibben L, Roberts H, Rhew D, Bratzler D. Factors predictive of increased influenza and pneumococcal vaccination coverage in long-term care facilities: the CMS-CDC standing orders program Project. [see comment]. Journal of the American Medical Directors Association 2005;6(5):291-9.

Bardenheier BH1, Shefer AM, Lu PJ, Remsburg RE, Marsteller JA. Are standing order programs associated with influenza vaccination? NNHS, 2004. J Am Med Dir Assoc 2010;11(9):654-61. doi: 10.1016/j.jamda.2009.12.091

Bourdet SV, Kelley M, Rublein J, Williams DM. Effect of a pharmacist-managed program of pneumococcal and influenza immunization on vaccination rates among adult inpatients. American Journal of Health-System Pharmacy 2003;60(17):1767-71.

Britto MT, Pandzik GM, Meeks CS, Kotagal UR. Combining evidence and diffusion of innovation theory to enhance influenza immunization. Joint Commission Journal on Quality and Patient Safety 2006; 32(8):426-32.

Byrnes P, Fulton B, Crawford M. An audit of influenza vaccination rates. Australian Family Physician 2006;35(7):551-2.

Connors CM, Miller NC, Krause VL. Universal hepatitis B vaccination: hospital factors influencing first-dose uptake for neonates in Darwin. Australian & New Zealand Journal of Public Health 1998;22(1):143-5.

Coyle CM, Currie BP. Improving the rates of inpatient pneumococcal vaccination: impact of standing orders versus computerized reminders to physicians. Infection Control & Hospital Epidemiology 2004;25(11):904-7.

Daniels NA, Gouveia S, Null D, Gildengorin GL, Winston CA. Acceptance of Pneumococcal vaccine under standing orders by race and ethnicity. JNMA 2006;98(7):1089-94.

deHart MP, Salinas SK, Barnette LJ, Jr., Lewis KD, Mustin HD, Corbett C et al. Project protect: pneumococcal vaccination in Washington state nursing homes. Journal of the American Medical Directors Association 2005;6(2):91-6.

Dexter PR, Perkins SM, Maharry KS, Jones K, McDonald CJ. Inpatient computer-based standing orders vs physician reminders to increase influenza and pneumococcal vaccination rates: a randomized trial. JAMA 2004;292:2366-71.

Donato AA, Motz LM, Wilson G, Lloyd BJ. Efficacy of multiple influenza vaccine delivery systems in a single facility. Infection Control & Hospital Epidemiology 2007;28(2):219 -21.

Eckrode C, Church N, English III WJ. Implementation and evaluation of a nursing assessment/standing orders-based inpatient pneumococcal vaccination program. Am J Infect Control 2007;35(8):508-15.

Gamble GR, Goldstein AO, Bearman RS. Implementing a standing order immunization policy: a minimalist intervention. JABFM 2008;21(1):38-44.

Ginson SH, Malmberg C, French DJ. Impact on vaccination rates of a pharmacist-initiated influenza and pneumococcal vaccination program. Can J Hosp Pharm 2000;53(4):270-75.

Gruber T, Marada R. Improving pneumococcal vaccination rates for elderly patients. New Jersey Medicine 2000;97(2):35-9.

Honeycutt AA, Coleman MS, Anderson WL, Wirth KE. Cost-effectiveness of hospital vaccination programs in North Carolina (Provisional record). Vaccine 2007;25:1484-96.

Kleschen MZ, Holbrook J, Rothbaum AK, Stringer RA, McInerney MJ, Helgerson SD. Improving the pneumococcal immunization rate for patients with diabetes in a managed care population: a simple intervention with a rapid effect. Joint Commission Journal on Quality Improvement 2000;26(9):538-46.

Lawson F, Baker V, Au D, McElhaney JE. Standing orders for influenza vaccination increased vaccination rates in inpatient settings compared with community rates. Journals of Gerontology Series A-Biological Sciences & Medical Sciences 2000;55(9):M522-6.

Loughlin SM, Mortazavi A, Garey KW, Rice GK, Birtcher KK. Pharmacist-managed vaccination program increased influenza vaccination rates in cardiovascular patients enrolled in a secondary prevention lipid clinic. Pharmacotherapy 2007;27(5):729-33.

Logue E, Dudley P, Imhoff T, Smucker W, Stapin J, DiSabato J, Schueller C. An opt-out influenza vaccination policy improves immunization rates in primary care. J Health Care Poor Underserved 2011;22(1):232-42. doi: 10.1353/hpu.2011.0009.

Melinkovich P, Hammer A, Staudenmaier A, Berg M. Improving pediatric immunization rates in a safety-net delivery system. Joint Commission Journal on Quality & Patient Safety 2007; 33(4):205-10.

Nichol KL. Ten-year durability and success of an organized program to increase influenza and pneumococcal vaccination rates among high-risk adults. American Journal of Medicine 1998;105(5):385-92.

Nowalk MP, Zimmerman RK, Lin CJ, et al. Raising adult vaccination rates over 4 years among racially diverse patients at inner-city health centers. Journal of the American Geriatrics Society 2008;56(7):1177-82.

Parry MF, Grant B, Iton A, Parry PD, Baranowsky D. Influenza vaccination: a collaborative effort to improve the health of the community. Infection Control & Hospital Epidemiology 2004;25(11):929-32.

Rhew DC, Glassman PA, Goetz MB. Improving pneumococcal vaccine rates. Nurse protocols versus clinical reminders. Journal of General Internal Medicine 1999;14:351-6.

Slobodkin D, Zielske PG, Kitlas JL, McDermott MF, Miller S, Rydman R. Demonstration of the feasibility of emergency department immunization against influenza and pneumococcus. Annals of Emergency Medicine 1998;32(5):537-43.

Slobodkin D, Kitlas JL, Zielske PG. A test of the feasibility of pneumococcal vaccination in the emergency department. Academic Emergency Medicine 1999;6(7):724-7.

Sokos DR, Skledar SJ, Ervin KA, Nowalk MP, Zimmerman RK, Fox DE, et al. Designing and implementing a hospital-based vaccine standing orders program. American Journal of Health-System Pharmacy 2007;64(10):1096-102.

Stevenson KB, McMahon JW, Harris J, Hillman JR, Helgerson SD. Increasing pneumococcal vaccination rates among residents of long-term-care facilities: provider-based improvement strategies implemented by peer-review organizations in four western states. Infect Control Hosp Epidemiol 2000;21(11):705-10.

Swenson CJ, Appel A, Sheehan M, et al. Using information technology to improve adult immunization delivery in an integrated urban health system. Joint Commission Journal on Quality & Patient Safety 2012;38(1):15-23.

Weaver FM, Smith B, LaVela S, Wallace C, Evans CT, Hammond M, et al. Interventions to increase influenza vaccination rates in veterans with spinal cord injuries and disorders. Journal of Spinal Cord Medicine 2007;30(1):10-9.

Veltri KT; Ferguson-Myrthil N; Currie B. The STanding Orders Protocol (STOP): a pharmacy driven pneumococcal and influenza vaccination program. Hosp Pharm 2009;44:874 80.

Zimmerman RK, Nowalk MP, Raymund M, Tabbarah M, Hall DG, Wahrenberger JT, et al. Tailored interventions to increase influenza vaccination in neighborhood health centers serving the disadvantaged. American Journal of Public Health 2003;93(10):1699-705.

Zimmerman RK, Hoberman A, Nowalk MP, Lin CJ, Greenberg DP, Weinberg ST, et al. Improving influenza vaccination rates of high-risk inner-city children over 2 intervention years. Annals of Family Medicine 2006;4(6):534-40.

Zimmerman RK1, Nowalk MP, Tabbarah M, Hart JA, Fox DE, Raymund M, FM Pitt-Net Primary Care Research Network. Understanding adult vaccination in urban, lower-socioeconomic settings: influence of physician and prevention systems. Ann Fam Med 2009;7(6):534-41. doi: 10.1370/afm.1060.

Economic Review

Healy CM, Rench MA, Baker CJ. Implementation of cocooning against pertussis in a high-risk population. Clin Infect Dis 2011;52(2):157. http://dx.doi.org/10.1093/cid/ciq001.

Honeycutt AA, Coleman MS, Anderson WL, Wirth KE. Cost-effectiveness of hospital vaccination programs in North Carolina. Vaccine 2007;25(8):1484-96. http://dx.doi.org/10.1016/j.vaccine.2006.10.029.

Middleton DB, Lin CJ, Smith KJ, et al. Economic evaluation of standing order programs for pneumococcal vaccination of hospitalized elderly patients. Infect Control Hosp Epidemiol 2008;29(5):385-94. http://dx.doi.org/10.1086/587155.

Effectiveness Review

The CPSTF findings are based on studies included in the original review (search period 1980-1997) combined with studies identified in the updated search (search period 1997- February 2012). Reference lists of articles reviewed as well as lists in review articles were also searched, and members of our coordination team were consulted for additional references.

Details of the original search (1980-1997)

The following five electronic databases were searched during the original review period of 1980 up to 1997: MEDLINE, Embase, Psychlit, CAB Health, and Sociological Abstracts. The team also reviewed reference lists in articles and consulted with immunization experts. To be included in the review, a study had to:

• have a publication date of 1980 1997;
• address universally recommended adult, adolescent, or childhood vaccinations;
• be a primary study rather than, for example, a guideline or review;
• take place in an industrialized country or countries;
• be written in English;
• meet the evidence review and Guide chapter development team’s definition of the interventions; provide information on one or more outcomes related to the analytic frameworks; and
• compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive.

Details of the update search (1997- February 2012)

The team conducted a broad literature search to identify studies assessing the effectiveness of Vaccine Preventable Disease interventions in improving vaccination rates. The following nine databases were searched during the period of 1997 up to February 2012: CABI, CINAHL, The Cochrane Library, EMBASE, ERIC, MEDLINE, PSYCHINFO, Soci Abs and WOS. Reference lists of articles reviewed as well as lists in review articles were also searched, and subject matter experts consulted for additional references. To be included in the updated review, a study had to:

• have a publication date of 1997- February 2012;
• evaluate vaccinations with universal recommendations;
• meet the evidence review and Guide chapter development team’s definition of the interventions;
• be a primary research study with one or more outcomes related to the analytic frameworks;
• take place in an high income country or countries;
• be written in English
• compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive

Search Terms

1. Immunization
2. Vaccination
3. Immunization Programs

Economic Review

The present review included studies that reported economic outcomes from the 2000 review (search period 1980-1997) combined with studies identified from updated searches (search period 1997- February 2012) within the standard medical and health-related research databases, Google Scholar, and databases specialized to economics and social sciences. The details of the two sets of searches are provided below.

Details of the Updated Search (1997- February 2012)

The team conducted a broad literature search to identify studies assessing interventions to improve vaccination rates. The following nine databases were searched during the period of 1997 up to February 2012: CABI, CINAHL, The Cochrane Library, EMBASE, ERIC, MEDLINE, PSYCHINFO, Soci Abs and WOS. In addition, Google Scholar and specialized databases (CRD-University of York: NHS EED, EconLit, and JSTOR), were also searched. Reference lists of articles reviewed as well as lists in review articles were also considered, and subject matter experts consulted for additional references.

Search Terms

• Immunization
• Vaccination
• Immunization Programs

To be included in the updated review, a study had to do the following:

• Have a publication date of 1997- February 2012
• Evaluate vaccinations with universal recommendations
• Meet the evidence review and Community Guide review team’s definition of the interventions
• Be a primary research study with one or more outcomes related to the analytic framework(s)
• Take place in a high income country or countries
• Be written in English; and
• Compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed.

Details of the Original Search (1980-1997)

The following five electronic databases were searched during the original review period of 1980 up to 1997: MEDLINE, Embase, Psychlit, CAB Health, and Sociological Abstracts. The team also reviewed reference lists in articles and consulted with immunization experts. To be included, a study had to do the following:

• Have a publication date of 1980 1997
• Address universally recommended adult, adolescent, or childhood vaccinations
• Be a primary study rather than, for example, a guideline or review
• Take place in an industrialized country or countries
• Be written in English
• Meet the definition of the interventions
• Provide information on one or more outcomes related to the analytic frameworks; and
• Compare a group of persons who had been exposed to the intervention with a group who had not been exposed or who had been less exposed. In addition, we excluded studies with least suitable designs for two interventions (provider reminder/recall and client reminder/recall) where the literature was most extensive.

• Standing order interventions may improve the efficiency and flow of patient care in busy inpatient and outpatient care settings.
• Included studies reported the following barriers to implementation:
  • Gaps in staff education, training, and perceived benefit
  • Personnel concerns about additional workload
  • Staff reluctance to administer vaccines without a physician’s order
  • Attending physicians’ resistance to having hospitalized patients vaccinated
  • Logistical difficulties
  • Concern that vaccination would interfere with scheduled treatments or procedures

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Reduce the proportion of children who get no recommended vaccines by age 2 years — IID‑02
• Maintain the vaccination coverage level of 1 dose of the MMR vaccine in children by age 2 years — IID‑03
• Maintain the vaccination coverage level of 2 doses of the MMR vaccine for children in kindergarten — IID‑04
• Increase the coverage level of 4 doses of the DTaP vaccine in children by age 2 years — IID‑06
• Increase the proportion of people who get the flu vaccine every year — IID‑09
• Increase the proportion of adults age 19 years or older who get recommended vaccines — IID‑D03