Journal Review: EDs best way to deliver pneumonia vaccine?

Husain S, Slobodkin D, Weinstein R. Pneumococcal vaccination: Analysis of opportunities in an inner-city hospital. Arch Intern Med 2002: 262;1,961-1,965.

Emergency departments (ED) in inner-city hospitals appear to be the best site within the facility to offer pneumococcal vaccine to high-risk patients, the authors found.

Pneumococcal vaccination rates in the United States are reported to be 28% to 47%, well below the desired 90% levels, with the result that many patients are denied effective protection against a major cause of morbidity and mortality. This study demonstrates that an ED-based vaccination strategy would protect most patients at risk for pneumococcal bacteremia in an inner-city public hospital, with a best-case scenario showing cost savings.

There were more than 100.4 million ED visits in the United States in 1998, the authors said. The ill, the elderly, the poor, and members of ethnic minorities are overrepresented in that group. These patients are at higher risk of respiratory disease and of undervaccination, the authors concluded.

"Pneumococcal bacteremia is a major cause of morbidity and mortality in the United States, with a yearly incidence estimated to be 15 to 30 cases per 1000,000 population," they emphasized. "This vaccine-preventable disease kills more Americans than all other vaccine-preventable diseases combined, in large part, because of inadequate rates of vaccination among populations at risk."

Various sites within the hospital — inpatient medicine wards (IMW), general medicine clinics (GMC), and emergency departments (ED) have been previously suggested as venues for administering vaccination.

The authors sought to compare the potential coverage of at-risk patients and cost of pneumococcal vaccination delivered in an ED, GMC, and IMWs.

They studied a retrospective cohort of 300 patients with pneumococcal bacteremia who had been hospitalized at Cook County Hospital in Chicago from January 1994 through December 1998. Researchers measured the presence of risk factors, as defined by the Centers for Disease Control and Prevention, for developing pneumococcal disease prior to index admission for bacteremia. They also looked at patient use of ED, GMC, and IMWs from four weeks to five years before index admission; size of target population for vaccination in each site; and cost benefit of a pneumococcal vaccination strategy at each site.

In the four weeks to five years before index admission, risk factors were present in 209 patients; 182 (87.1%) of the 209 had been in the ED, 104 (49.7%) in an IMW, and 64 (30.6%) in a GMC. The ED showed the greatest potential vaccine coverage, at a cost savings in a best-case scenario. The IMWs showed the best cost-benefit ratio but would provide access to fewer at-risk patients.

A program in the GMC would reach the fewest at-risk patients, with a cost-benefit ratio similar to that of the ED.